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Patient Name
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First Name
Last Name
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2
Date
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Date
Month
Day
Year
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3
Over the past two weeks, how often have you been bothered by any of the following problems?
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Not At All
Several Days
More than Half the Days
Nearly Every Day
Little interest or pleasure in doing things
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Feeling down depressed or hopeless
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Trouble falling sleep, staying asleep, or sleeping too much
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Feeling tired or having little energy
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Poor appetite or overeating
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Feeling bad about yourself – or that you’re a failure or have let yourself or your family down
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Trouble concentrating on things, such as reading the newspaper or watching television
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
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
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Thoughts that you would be better off dead or of hurting yourself in some way
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Little interest or pleasure in doing things
Feeling down depressed or hopeless
Trouble falling sleep, staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself – or that you’re a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
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
Thoughts that you would be better off dead or of hurting yourself in some way
Not At All
Row 0, Column 0
Several Days
Row 0, Column 1
More than Half the Days
Row 0, Column 2
Nearly Every Day
Row 0, Column 3
Not At All
Row 1, Column 0
Several Days
Row 1, Column 1
More than Half the Days
Row 1, Column 2
Nearly Every Day
Row 1, Column 3
Not At All
Row 2, Column 0
Several Days
Row 2, Column 1
More than Half the Days
Row 2, Column 2
Nearly Every Day
Row 2, Column 3
Not At All
Row 3, Column 0
Several Days
Row 3, Column 1
More than Half the Days
Row 3, Column 2
Nearly Every Day
Row 3, Column 3
Not At All
Row 4, Column 0
Several Days
Row 4, Column 1
More than Half the Days
Row 4, Column 2
Nearly Every Day
Row 4, Column 3
Not At All
Row 5, Column 0
Several Days
Row 5, Column 1
More than Half the Days
Row 5, Column 2
Nearly Every Day
Row 5, Column 3
Not At All
Row 6, Column 0
Several Days
Row 6, Column 1
More than Half the Days
Row 6, Column 2
Nearly Every Day
Row 6, Column 3
Not At All
Row 7, Column 0
Several Days
Row 7, Column 1
More than Half the Days
Row 7, Column 2
Nearly Every Day
Row 7, Column 3
Not At All
Row 8, Column 0
Several Days
Row 8, Column 1
More than Half the Days
Row 8, Column 2
Nearly Every Day
Row 8, Column 3
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