Depression Screening Form

Name
Email
Phone
How would you like to be contacted?	Email Me Call Me
*Answer each question with regard to how you have felt over the last two weeks.* *Please check in the appropriate box.*
Topic	Not at all	Several Days	More than 50% of the days	Nearly every day
Do you have little interest or pleasure in doing things ?
Are you feeling down, depressed, or hopeless?
Do you have trouble falling or staying asleep, or sleeping to much
Do you feel tired or have little energy
Is your appetite poor or are you overeating
Do you feel bad about your self, that you are a failure, etc.
Do you have trouble concentrating on tasks or activities
Are you moving or speaking slowly, or being fidgety & restless
Do you have thoughts that you would be better off dead or of hurting yourself or someone
If you checked any of the problems, how difficult have they made it for you to work, take care of things at home or get along with others?

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Copyright 1997 - 2004 Tom Porpiglia
Last Revised: 04/10/08