| NAME:___________________________________________ |
DATE:______________________ |
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| Over the last 2 weeks, how often
have you been bothered by any of the following problems?
(please circle your
answers) | 
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1. |
Little interest or pleasure in
doing things |
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0 |
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1 |
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2 |
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3 |
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2. |
Feeling down, depressed, or hopeless |
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0 |
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1 |
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2 |
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3 |
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3. |
Trouble falling or staying asleep,
or sleeping too much |
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0 |
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1 |
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2 |
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3 |
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4. |
Feeling tired or having little
energy |
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0 |
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1 |
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2 |
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3 |
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5. |
Poor appetite or overeating |
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0 |
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1 |
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2 |
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3 |
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6. |
Feeling bad about yourself—or that
you are a failure or have let yourself
or your family down |
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0 |
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1 |
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2 |
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3 |
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7. |
Trouble concentrating on things,
such as reading the newspaper or watching television |
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0 |
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1 |
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2 |
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3 |
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8. |
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 |
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0 |
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1 |
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2 |
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3 |
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9. |
Thoughts that you would be better
off dead,
or of hurting yourself in some way |
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0 |
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1 |
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2 |
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3 |
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add
columns 2, 3 and 4: |
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+ |
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+ |
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(Healthcare
professional: For interpretation of TOTAL, TOTAL:
please refer to accompanying scoring card). |
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10. |
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?
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Not difficult at all |
_________ |
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Somewhat difficult |
_________ |
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Very difficult |
_________ |
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Extremely difficult |
_________ |
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