Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

1. Over the last 2 weeks, how often have you been bothered by the following problems? Little interest or pleasure in doing things *

Not at all (0)

Several days (+1)

More than half the days (+2)

Nearly every day (+3)

2. Over the last 2 weeks, how often have you been bothered by the following problems? Feeling down, depressed or hopeless *

Not at all (0)

Several days (+1)

More than half the days (+2)

Nearly every day (+3)

3. Over the last 2 weeks, how often have you been bothered by the following problems? Trouble falling asleep, staying asleep, or sleeping too much *

Not at all (0)

Several days (+1)

More than half the days (+2)

Nearly every day (+3)

4. Over the last 2 weeks, how often have you been bothered by the following problems? Feeling tired or having little energy *

Not at all (0)

Several days (+1)

More than half the days (+2)

Nearly every day (+3)

5. Over the last 2 weeks, how often have you been bothered by the following problems? Poor appetite or overeating *

Not at all (0)

Several days (+1)

More than half the days (+2)

Nearly every day (+3)

6. Over the last 2 weeks, how often have you been bothered by the following problems? Feeling bad about yourself - or that you’re 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)

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

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

Option 1

Several days (+1)

More than half the days (+2)

Nearly every day (+3)

9. Over the last 2 weeks, how often have you been bothered by the following problems? Thoughts that you would be better off dead or of hurting yourself in some way *

Option 1

Several days (+1)

More than half the days (+2)

Nearly every day (+3)