Depression Screening
Please Re-enter your Name and Date of birth on this form
What is your name?
*
Please enter the patients name
Date of Birth Calc
What is your date of birth?
*
Please enter the patients date of birth
Current Date (calc)
-
Month
-
Day
Year
Date
Back
Next
Little interest or pleasure in doing things
Not at all
Several days
More than half the time
Nearly every day
Feeling down, depressed, or hopeless
Not at all
Several days
More than half the time
Nearly every day
Trouble falling/staying asleep, sleeping too much
Not at all
Several days
More than half the time
Nearly every day
Feeling tired or having little energy
Not at all
Several days
More than half the time
Nearly every day
Poor appetite or overeating
Not at all
Several days
More than half the time
Nearly every day
Back
Next
Feeling bad about yourself or that you are a failure or have let yourself or your family down
Not at all
Several days
More than half the time
Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television
Not at all
Several days
More than half the time
Nearly every day
Moving or speaking so slowly that other people could have noticed. Or the opposite; being so fidgety or restless that you have been moving around a lot more than usual.
Not at all
Several days
More than half the time
Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way
Not at all
Several days
More than half the time
Nearly every day
If you checked off any problems on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not at all
Several days
More than half the time
Nearly every day
Total
Calculation
Next Survey form
Should be Empty: