Online Health Questionnaire

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Depression Screening & Suicidality Index (DSSI)

Depression Screening & Suicidality Index (DSSI)

This screening tool is totally anonymous and available free for use .

6Questions

HIPAA

Compliance

1
We will neither ask for your name or contact information in this form nor will any of this information be attached to you in any way.

This screening process is not meant to be a formal diagnosis. Rather it's our way of helping you identify if your mental health or that of your loved ones would benefit from being evaluated by a mental health professional.

If you would like to share this screening tool on your organization's website, please click here and submit a request.
2
Do you feel you suffer from depression or have you been diagnosed with major depressive disorder?* This field is required.
Yes
No
3
Do you suffer from any of the mental health condition(s) below?You have the option of selecting Other and entering the specific condition.
Anxiety disorder or nervousness
Bipolar disorder
PTSD (post-traumatic stress disorder)
Schizophrenia
4
How old are you?* This field is required.
5
If you feel you may be dealing with depression, please answer the following nine (9) questions.

Consider your response only for the past 2 weeks.

Over the last 2 weeks, how many days have you been bothered by any of the following problems?
6
Little interest or pleasure in doing things
Not at all (zero days in past 2 weeks)
A few days (about 3-4 days in past 2 weeks)
Over half the days (more than 7 days in past 2 weeks)
Nearly every day (12 to 14 days in the past 2 weeks)
7
Feeling down, depressed or hopeless
Not at all (zero days in past 2 weeks)
A few days (about 3-4 days in past 2 weeks)
Over half the days (more than 7 days in past 2 weeks)
Nearly every day (12 to 14 days in the past 2 weeks)
8
Trouble falling asleep, or sleeping a lot
Not at all (zero days in past 2 weeks)
A few days (about 3-4 days in past 2 weeks)
Over half the days (more than 7 days in past 2 weeks)
Nearly every day (12 to 14 days in the past 2 weeks)
9
Feeling tired or having little energy
Not at all (zero days in past 2 weeks)
A few days (about 3-4 days in past 2 weeks)
Over half the days (more than 7 days in past 2 weeks)
Nearly every day (12 to 14 days in the past 2 weeks)
10
Poor appetite, or overeating
Not at all (zero days in past 2 weeks)
A few days (about 3-4 days in past 2 weeks)
Over half the days (more than 7 days in past 2 weeks)
Nearly every day (12 to 14 days in the past 2 weeks)
11
Feeling bad about yourself - or that you're a failure or have let yourself or your family down
Not at all (zero days in past 2 weeks)
A few days (about 3-4 days in past 2 weeks)
Over half the days (more than 7 days in past 2 weeks)
Nearly every day (12 to 14 days in the past 2 weeks)
12
Trouble concentrating on things such as reading the newspaper or watching TV
Not at all (zero days in past 2 weeks)
A few days (about 3-4 days in past 2 weeks)
Over half the days (more than 7 days in past 2 weeks)
Nearly every day (12 to 14 days in the past 2 weeks)
13
Moving or speaking so slowly that other people could notice
Not at all (zero days in past 2 weeks)
A few days (about 3-4 days in past 2 weeks)
Over half the days (more than 7 days in past 2 weeks)
Nearly every day (12 to 14 days in the past 2 weeks)
14
Thoughts that you'd be better off dead, or of hurting yourself
Not at all (zero days in past 2 weeks)
A few days (about 3-4 days in past 2 weeks)
Over half the days (more than 7 days in past 2 weeks)
Nearly every day (12 to 14 days in the past 2 weeks)
15
The patient has indicated they are having thoughts of hurting themselves or being better off dead on a daily basis for the past 2 weeks (Q9 from PHQ-9 Depression Screen).
16
The patient denied any desire to harm themselves or anyone else.
17
Total Score of Depression Screen (PHQ-9)
Maximum score is 27
18
Are you in crisis?

If you are in crisis, please call 911 or the National Suicide Prevention Hotline at 1-800-273-TALK or go immediately to the nearest emergency room.

You may be at risk of harming yourself or someone else.
19
Minimal Depression

Your results indicate that you have none, or very few symptoms of depression.

If you notice that your symptoms aren't improving, you may want to bring them up with someone you trust.

This screen is not meant to be a diagnosis, or the elimination of a diagnosis. A trained medical or mental health professional can help clarify issues and diagnose depression.

If you feel like your feelings, thoughts, or behaviors get worse, screen again.
20
Mild Depression

Your results indicate that you may be experiencing some symptoms of mild depression. While your symptoms are not likely to have a major impact on your life, it is important to monitor them.

These results do not mean that you have depression, but it may be time to start a conversation with someone you trust.

This screen is not meant to be a diagnosis. Diagnosis and care of mental health conditions can be difficult. Having symptoms of depression is different than having depression. A trained professional, such as a doctor or a mental health provider, can make this determination, and finding the right support can help you feel more like you again.
21
Moderate Depression

Your results indicate that you may be experiencing symptoms of moderate depression. Based on your answers, living with these symptoms could be causing difficulty managing relationships and even the tasks of everyday life.

These results do not mean that you have depression, but it may be time to start a conversation with someone you trust.

This screen is not meant to be a diagnosis. Diagnosis and care of mental health conditions can be difficult. A trained professional, such as a doctor or a mental health provider, can make this determination, and finding the right support can help you feel more like you again.
22
Moderately Severe Depression

Your results indicate that you may be experiencing symptoms of moderately severe depression. Based on your answers, living with these symptoms is causing difficulty managing relationships and even the tasks of everyday life.

These results do not mean that you have depression, but it may be time to start a conversation with someone you trust.

This screen is not meant to be a diagnosis. Diagnosis and care of mental health conditions can be difficult. Having symptoms of depression is different than having depression. A trained professional, such as a doctor or a mental health provider, can make this determination, and finding the right support can help you feel more like you again.
23
Severe Depression

Your results indicate that you may be experiencing symptoms of severe depression. Based on your answers, these symptoms seem to be greatly interfering with your relationships and the tasks of everyday life.

These results do not mean that you have depression, but it may be time to start a conversation with someone you trust.

This screen is not meant to be a diagnosis. Diagnosis and care of mental health conditions can be difficult. Having symptoms of depression is different than having depression. A trained professional, such as a doctor or a mental health provider, can make this determination, and finding the right support can help you feel more like you again.
24
SUICIDE RISK FACTORS IDENTIFIED:
25
The patient's response also indicates they may be at risk of harming themselves or others.
26
Minimal Depression
27
Mild Depression
28
Moderate Depression
29
Moderately Severe Depression
30
Severe Depression
31
WR-5 Depression
32
Are you feeling hopeless about the present or the future?
Yes
No
33
Depression Inconsistency Meter 1
34
PHYSICIAN ALERT: INCONSISTENT RESPONSE DETECTED
35
Patient has confirmed they feel hopeless.
36
Have you had thoughts about taking your life?
Yes
No
37
When did you have these thoughts about taking your life?
38
The patient may be in crisis and experiencing suicidal ideation given that they have had thoughts about taking their life.
39
Do you have an actual plan to take your life?
Yes
No
40
Can you please share your plan on how you want to take your life?
41
The patient does admit to having a suicide plan.
42
The patient does not have a suicide plan.
43
Have you attempted suicide in the past?
Yes
No
44
Severe/Moderate
45
Concomitant
46
Age (Depression)
47
Every Day
48
Plan
49
Prior Attempt
50
Hopelessness
51
Depression Scale
52
The patient does have a history of attempted suicide.
53
The patient does not have a history of attempted suicide.
54
Patient is between the ages of 18-25, which is a risk factor for suicide.
55
How long have you been suffering from depression?
I recently found out
Within the past 6 months
About a year or more
Over 5 years
56
How difficult has your depression made it for you at work, home, or with other people?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
57
Depression - Mental Health Identifier/Difficulty/Length of Suffering (no Recent)
58
Depression - Mental Health Identifier/Difficulty/Length of Suffering (Recent)
59
Patient exhibits concerns about mental health, specifically depression, {ifYou55}.
60
Patient exhibits concerns about mental health, specifically {ifYou55}.
61
Patient reports a concomitant psychiatric disorder.
62
Please note that our online screening tool is not a diagnostic screening instrument.
63
Depression (PHQ-9) designed as screening tool
The PHQ-9 has been designed to screen for depression in the primary care setting and is a reliable and validated tool for depression severity. For a detailed breakdown of the patient's responses, please go to the section "PHQ-9" at the end of the form.
64
Anxiety GAD-7 Info
GAD-7 is designed as a self reported screening tool for diagnosis and severity assessment of anxiety disorder and has been validated for use in primary care settings. For a detailed breakdown of the patient's responses, please go to the section "GAD-7" at the end of the form.
65
PC-PTSD Info
PC-PTSD is designed as a self reported screening tool and has been validated for use in primary care settings to identify respondents with PTSD. For a detailed breakdown of the patient's responses, please go to the section "PC-PTSD" at the end of the form.
66
If you feel you may be dealing with anxiety, please answer the following seven (7) questions.

Consider your response only for the past 2 weeks.

Over the last 2 weeks, how often hae you been bothered by any of the following problems?
67
Feeling nervous, anxious or on the edge
Not at all
A few of the days
Over half the days
Nearly every day
68
Not being able to sleep or control worrying
Not at all
A few of the days
Over half the days
Nearly every day
69
Worrying too much about different things
Not at all
A few of the days
Over half the days
Nearly every day
70
Trouble relaxing
Not at all
A few of the days
Over half the days
Nearly every day
71
Being so restless that it is hard to sit still
Not at all
A few of the days
Over half the days
Nearly every day
72
Being easily annoyed or irritable
Not at all
A few of the days
Over half the days
Nearly every day
73
Being afraid, as if something awful might happen
Not at all
A few of the days
Over half the days
Nearly every day
74
Anxiety Calculation
75
WR-5 Anxiety
76
Minimal Anxiety

Your answers indicate that you have very few signs of anxiety.

If you notice that your symptoms are not improving or getting worse, you may want to bring them up with someone you trust.

This statement is not meant to be a diagnosis, nor the elimination of a diagnosis. A trained medical or mental health professional may help clarify issues and diagnose anxiety for you.
77
Mild Anxiety

Your answers indicate that you have maybe experienced some symptoms of mild anxiety. While symptoms are not likely to have a major impact on your life, it is important to monitor them.

This screen is not meant to be a diagnosis but is a good way to identify if anxiety is a possible problem. Having symptoms of anxiety is different than having an anxiety disorder. A trained professional such as a doctor or mental health provider can help make this determination, and finding the right support can help you feel more at ease.
78
Moderate Anxiety

Your results indicate that you may be experiencing symptoms of moderate anxiety. Based on your answers, living with these symptoms could be causing difficulty managing relationships and even the tasks of everyday life.

These results do not mean that you have an anxiety disorder, but it may be time to start a conversation with someone you trust to explore what is going on and how things can get better.

This screen is not meant to be a formal diagnosis but is a good way to identify if anxiety is a possible problem. Having symptoms of anxiety is different than having an anxiety disorder. A trained professional, such as a doctor or a mental health provider, can make this determination.
79
Severe Anxiety

Your results indicate that you may be experiencing symptoms of severe anxiety. Based on your answers, these symptoms seem to be greatly interfering with your relationships and the tasks of everyday life.

These results do not mean that you have anxiety disorder, but it may be time to start a conversation with someone you trust to explore what is going on and how things can get better.

This screen is not meant to be a formal diagnosis but is a good way to identify if anxiety is a possible problem. Having symptoms of anxiety is different than having an anxiety disorder. A trained professional, such as a doctor or a mental health provider, can make this determination.
80
Minimal Anxiety
81
Mild Anxiety
82
Moderate Anxiety
83
Severe Anxiety
84
Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example:

A serious accident or fire

A physical or sexual assault or abuse

An earthquake or flood

A war

Seeing someone be killed or seriously injured

Having a loved one die through homicide or suicide.
85
Have you ever experienced an event like the ones listed in the prior screen?
Yes
No
86
No - Patient reports having PTSD
Patient reports having PTSD, but has not had a severely horrible or traumatic experience, such as a serious accident or fire, physical or sexual assault or abuse, an natural disaster such as an earthquake or flood, a war, witnessing a homicide or serious injury, or experiencing the death of a loved one through homicide or suicide.
87
Have you had nightmares about it or thought about it when you did not want to?
Yes
No
88
Have you tried hard not to think about it or went out of your way to avoid situations that reminded you of it?
Yes
No
89
Were you constantly on guard, watchful, or easily startled after the event?
Yes
No
90
Did you feel numb or detached from others, activities, or your surroundings after the event?
Yes
No
91
Did you feel guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?
Yes
No
92
PTSD Negative

Based on your answers, you have little or no symptoms of Post Traumatic Stress Disorder.

If you notice that your symptoms aren't improving or get worse, you may want to bring them up with your doctor or rescreen.

The results of the screen do not show whether a person has PTSD. A screen can only show whether this person should be assessed further.

This screen is not meant to be a diagnosis or the elimination of a diagnosis. Only a trained medical professional can diagnose Post Traumatic Stress Disorder.
93
PTSD Positive

Based on your responses, you may be experiencing symptoms of Post Traumatic Stress Disorder. Living with these symptoms could be causing difficulty managing relationships and even the tasks of everyday life.

These results do not mean that you have Post Traumatic Stress Disorder, but it may be time to start a conversation with your doctor. Finding the right treatment plan and working with your doctor or healthcare provider can help you feel more like you again.

The results of the screen do not show whether a person has PTSD. A screen can only show whether this person should be assessed further.

This screen is not meant to be a diagnosis. Diagnosis and care of mental health conditions can be difficult. Having symptoms of Post Traumatic Stress Disorder is different than having Post Traumatic Stress Disorder. In addition, symptoms of Post Traumatic Stress Disorder can be caused by other mental health conditions, or other health problems. Only a trained professional, such as a doctor or a mental health provider, can make this determination.
94
PTSD Calculation
95
PTSD Truth
96
Yes - PTSD Truth
Patient reports experiencing symptoms of PTSD, which was corroborated by the PC-PTSD, a 5-item screen that was designed for use in primary care and other medical settings and is currently used to screen for PTSD in veterans at the VA.
97
No - PTSD Truth
Patient reports experiencing symptoms of PTSD, which was not corroborated by the PC-PTSD, a 5-item screen that was designed for use in primary care and other medical settings and is currently used to screen for PTSD in veterans at the VA.
98
How long have you been suffering from {ifYou55}?
I recently found out
Within the past 6 months
About a year or more
Over 5 years
99
How difficult have these problems made it for you at work, home, or with other people?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
100
Mental Health Identifier/Difficulty/Length of Suffering (no Recent)
101
Mental Health Identifier/Difficulty/Length of Suffering (Recent)
102
Do you feel that this experience has benefited your awareness of your mental health?* This field is required.
1
2
3
4
5
Strongly Disagree
Strongly Agree
103
Do you know someone who might benefit from this tool? Share this with your friends on social media.
104
Referrer
105
If you are interested in seeing if medical cannabis may benefit you, please select yes to go through our Online Health Questionnaire.
Yes
No
106
107
Unique ID
Should be Empty:

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