Name *

First Name

Last Name

Little interest or pleasure in doing things *

0. Not at all

1. Several days

2. More than half the days

3. Nearly every day

Feeling down, depressed or hopeless *

0. Not at all

1. Several days

2. More than half the days

3. Nearly every day

Trouble falling or staying asleep, or sleeping too much *

0. Not at all

1. Several days

2. More than half the days

3. Nearly every day

Poor appetite or overeating *

0. Not at all

1. Several days

2. More than half the days

3. Nearly every day

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

0. Not at all

1. Several days

2. More than half the days

3. Nearly every day

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

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

Thoughts that you would be better off dead or hurting yourself in some way *

0. Not at all

1. Several days

2. More than half the days

3. Nearly every day