Patient Depression Questionnaire

Call Us609-704-1313121 South White Horse Pike, Hammonton, NJ 08037Email Usinfo@unityplaceofac.com

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Over the last 2 weeks, how often have you been bothered by any of the following problems?

Name *

Date

Little interest or pleasure in doing things

Not at all
Several days
More than half the days
Nearly every day

Feeling down, depressed, or hopeless

Not at all
Several days
More than half the days
Nearly every day

Trouble falling or staying asleep, or sleeping too much

Not at all
Several days
More than half the days
Nearly every day

Feeling tired or having little energy

Not at all
Several days
More than half the days
Nearly every day

Poor appetite or overeating

Not at all
Several days
More than half the days
Nearly every day

Feeling bad about yourself — or that you are a failure or have let yourself or your family down

Not at all
Several days
More than half the days
Nearly every day

Trouble concentrating on things, such as reading the newspaper or watching television

Not at all
Several days
More than half the days
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

Not at all
Several days
More than half the days
Nearly every day

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

Not at all
Several days
More than half the days
Nearly every day

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

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121 South White Horse Pike
Hammonton, NJ 08037

info@unityplaceofac.com

609-704-1313

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