top of page

If you've been sent this form, it is to gather some more information about your past history and medical health. Your answers are confidential.

Over the last 2 weeks, how often have you had little interest or pleasure in doing things?

Choose one answer from the dropdown that most closely represents your answer.

Over the last 2 weeks, how often have you felt down, depressed or hopeless?

Choose one answer from the dropdown that most closely represents your answer.

Over the last 2 weeks, how often have you had trouble falling asleep, staying asleep or sleeping too much?

Choose one answer from the dropdown that most closely represents your answer.

Over the last 2 weeks, how often have you been feeling tired or had little energy?

Choose one answer from the dropdown that most closely represents your answer.

Over the last 2 weeks, how often have you had a poor appetite or been overeating?

Choose one answer from the dropdown that most closely represents your answer.

Over the last 2 weeks, how often have you felt bad about yourself or that you are a failure or have let yourself or your family down?

Choose one answer from the dropdown that most closely represents your answer.

Over the last 2 weeks, how often have you had trouble concentrating on things such as reading the newspaper or watching television?

Choose one answer from the dropdown that most closely represents your answer.

Over the last 2 weeks, how often have you been 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?

Choose one answer from the dropdown that most closely represents your answer.

Over the last 2 weeks, how often have you had thoughts that you would be better off dead, or of hurting yourself?

Choose one answer from the dropdown that most closely represents your answer.

IF you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Choose one answer from the dropdown that most closely represents your answer.

Read the privacy policy about the collection of your private information. 

​

Return to the home page.

bottom of page