First Name

Last Name


For each item, please select Not True, Somewhat True, or Certainly True. It would help us if you answered all items as best you can, even if you are not absolutely certain. Please give your answers on the basis of how things have been for you over the last six months.

Not at All
More than Half the Days
Nearly Every Day
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself - or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed. Or so fidgety or restless that you have been moving a lot more than usual
Thoughts that you would be better off dead or thoughts of hurting yourself in some way

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 people?