Over the last 2 weeks, how often have you been bothered by any of the following problems? (circle your answer) Please print this page out and bring it to your next appointment.
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 or staying asleep, or sleeping
to 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
10. 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?
Not difficult at all _____
Somewhat difficult _____
Very difficult _____
Extremely difficult _____
Now that you are finished, please add up your totals for each individual number and print this page out to bring with you to your next appointment.
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