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Screening Form (2)
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Participant's First and Last Name
*
Your answer
Instructions:
How often have you been bothered by each of the following symptoms during the past
two weeks
?
For each symptom check the answer that best describes how you have been feeling:
1. Feeling down, depression, irritable, or hopeless?
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
Clear selection
2. Little interest or pleasure in doing things?
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
Clear selection
3. Trouble falling asleep, staying asleep, or sleeping in too much?
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
Clear selection
4. Poor appetite, weight loss, or overeating?
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
Clear selection
5. Feeling tired, or having little energy?
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
Clear selection
6. Feeling bad about yourself - or feeling 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
Clear selection
7. Trouble concentrating on things like school work, reading, or watching TV?
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
Clear selection
8. Moving or speaking so slowly that other people could have noticed?
Or the opposite - being so fidgety or restless the you were moving around a lot more than usual?
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
Clear selection
9. Thoughts that you would be better off dead, or of hurting yourself?
Not at all - 0
Several days - 1
More than half the days - 2
Nearly every day - 3
Clear selection
In the
past year
have you felt depressed or sad most days, even if you felt okay sometimes?
Yes
No
Clear selection
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?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Clear selection
Has there been a time in the past month when you have had serious thoughts about ending your life?
Yes
No
Clear selection
Have you
ever
, in your
whole life
, tried to kill yourself or made a suicide attempt?
Yes
No
Clear selection
If you have had thoughts that you would be better off dead or of hurting yourself in some way, please discuss this with your Health Care Clinician, go to a hospital emergency room or call 911.
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