Depression Screen Questionnaire | Oaks Place Surgery

Full Name *

Please include any middle names

Date of Birth

Date Today

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

Please choose one option for each question

Little interest or pleasure in doing things?

Not at all (0)

Several Days (1)

More than half the days (2)

Nearly every day (3)

Feeling down, depressed, or hopeless?

Not at all (0)

Several Days (1)

More than half the days (2)

Nearly every day (3)

Trouble falling or staying asleep, or sleeping too much?

Not at all (0)

Several Days (1)

More than half the days (2)

Nearly every day (3)

Feeling tired or having little energy?

Not at all (0)

Several Days (1)

More than half the days (2)

Nearly every day (3)

Poor appetite or overeating?

Not at all (0)

Several Days (1)

More than half the days (2)

Nearly every day (3)

Feeling bad about yourself - or that you are a failure or have let yourself or your family down?

Not at all (0)

Several Days (1)

More than half the days (2)

Nearly every day (3)

Trouble concentrating on things, such as reading the newspaper or watching television?

Not at all (0)

Several Days (1)

More than half the days (2)

Nearly every day (3)

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 (0)

Several Days (1)

More than half the days (2)

Nearly every day (3)

Thoughts that you would be better off dead, or of hurting yourself in some way?

Not at all (0)

Several Days (1)

More than half the days (2)

Nearly every day (3)

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