Name:   Date of Birth:

Over the last 2 weeks, how often have you been bothered by the following problems?

Feeling down, depressed or hopeless:


Little interest or pleasure in doing things:


Trouble falling asleep, staying asleep or sleeping too much:


Poor appetite or overeating:


Feeling tired or having little energy:


Feeling bad about yourself, or that you are a failure or have let yourself or your family down:


Trouble concentrating on things such as reading or watching television:


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:


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

In the past year have you felt depressed or sad most days, even if you felt okay sometimes?

If you are experiencing any of the problems on this form, 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?

Has there been a time in the past month when you have had serious thoughts about ending your life?

Have you EVER, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?

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