This easy to use patient questionnaire has been has been validated for use in Primary Care.

The questionnaire is a tool used by your doctor to monitor the severity of depression and response to treatment.

It can also be used to make a tentative diagnosis of depression.

Please contact your doctor if you are:

  • Concerned about your mood; or
  • Have completed this questionnaire and it indicates that you may be depressed.

Contact Details

Name(Required)
Date(Required)
Home Address(Required)

Questionnaire

Over the last two weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things(Required)
Feeling down, depressed, or hopeless(Required)
Trouble falling or staying asleep, or sleeping too much(Required)
Feeling tired or having little energy(Required)
Poor appetite or overeating(Required)
Feeling bad about yourself, or that you are a failure or have let yourself or your family down(Required)
Trouble concentrating on things, such as reading the newspaper or watching television(Required)
Moving or speaking so slowly that other people could have noticed(Required)
(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(Required)

Finally

Regarding the questions above, if you checked off “Several days”, “More than half the days” or “Nearly every day”; how
have these problems effected your ability to do your work, take care of things at home, or get along with other people?

The problems I've checked off above…(Required)