Patient First Name *

Patient Last Name *

Date of birth *

Phone Number *

Email *

Address

City

State

1. Little interest or pleasure in doing things *

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

2. Feeling down, depressed, or hopeless *

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

3. Trouble falling or staying asleep, or sleeping too much *

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

4. Feeling tired or having little energy *

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

5. Poor appetite or overeating *

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down *

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

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

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

8. Moving or speaking so slowly that other people could notice. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual *

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

9. Thoughts that you would be better off dead, or of hurting yourself *

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

Would you be interested in learning more about a safe, effective, non-drug treatment for depression? *

Yes

No