Name
*
First Name
Last Name
1. Little interest or pleasure in doing things
*
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
2. Feeling down, depressed or hopeless
*
0 Not at all
1 Several Days
2 More than half the days
3 Nearly every day
3. Trouble falling asleep, staying asleep, or sleeping too much
*
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
4. Feeling tired or having little energy
*
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
5. Poor appetite or overeating
*
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
6.Feeling bad about yourself - or that you are a failure or have let yourself or your family down
*
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
7. Trouble concentrating on things, such as reading the newspaper or watching television
*
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
8. 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
*
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
9. Thoughts that you would be better off dead or of hurting yourself in some way
*
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
Anything else you'd like us to know?
