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Depression Quiz
Curious if you have depression? Complete the form below and our office will contact you to go over your responses.
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Email
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Your email
First Name
*
Your answer
Last Name
Your answer
Date
*
Your answer
Over the last 2 weeks, how often have you been bothered by any of 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
Select one of the following:
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
Select one of the following:
Feeling down, depressed, or hopeless
*
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
Select one of the following:
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
Select one of the following:
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
Select one of the following:
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
Select one of the following:
Feeling tired or having too little energy
*
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
Select one of the following:
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
Select one of the following:
Poor appetite or overeating
*
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
Select one of the following:
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
Select one of the following:
Feeling bad about yourself - or that you are a failure or that you have let yourself or your family down
*
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
Select one of the following:
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
Select one of the following:
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
Select one of the following:
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
Select one of the following:
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
Select one of the following:
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
Select one of the following:
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
Select one of the following:
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
Select one of the following:
If you checked off any problems, 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?
*
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Select one of the following:
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Select one of the following:
Would you be interested in learning more about a safe, effective, non-drug treatment for depression?
*
Yes
No
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