Depression Questionnaire
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Provider Name
Patient Information
*
Please provide the patient's full legal name as it appears on their driver's license, state identification card, or government issued identification card.
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Gender
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* Required Information
Depression Questionnaire
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
Not at all
Several days
More than half the days
Nearly every day
*
b. Feeling down, depressed, or hopeless
Not at all
Several days
More than half the days
Nearly every day
*
c. Trouble falling or staying asleep, or sleeping too much
Not at all
Several days
More than half the days
Nearly every day
*
d. Feeling tired or having little energy
Not at all
Several days
More than half the days
Nearly every day
*
e. Poor appetite or overeating
Not at all
Several days
More than half the days
Nearly every day
*
f. 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 days
Nearly every day
*
g. Trouble concentrating on things, such as reading the newspaper or watching TV
Not at all
Several days
More than half the days
Nearly every day
*
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
Not at all
Several days
More than half the days
Nearly every day
*
i. Thoughts that you would be better off dead or of hurting yourself in some way
Not at all
Several days
More than half the days
Nearly every day
*
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?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 701
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