Please answer every section and mark in each section ONLY THE ONE which applies to you.

 

1. Over the past 2 weeks, how often have you been bothered by any of the following problems?

a. Little interest or pleasure in doing things
 
 
 
 
 
 
b. Feeling down, depressed, or hopeless
 
 
 
 
 
 
c. Trouble falling or staying asleep, or sleeping too much
 
 
 
 
 
 
d. Feeling tired or having little energy
 
 
 
 
 
 
e. Poor appetite or overeating
 
 
 
 
 
 
f. Feeling bad about yourself – or that you are a failure or have let yourself or your family down
 
 
 
 
 
 
g. Trouble concentrating on things, such as reading the newspaper or watching TV
 
 
 
 
 
 
h. 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
 
 
 
 
 
 
i. Thoughts that you would be better off dead or of hurting yourself in some way
 
 
 
 
 
 

2. If you checked off any problems on this questionnaire so far, how difficult have these problems made it for you to do work, take care of things at home, or get along with other people?

 
 
 
 
 
 

IMPORTANT: Please do not use the 'BACK' button on your browser while completing your history forms.
 
Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 701
This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the ‘Submit’ button when completed.