Depression Screener

Name:

Pronouns:

DOB:

Date:

Recognized/treated depression prior to today?

Yes No

How often have you been bothered by each of these symptoms during the past two weeks?

1. Feeling down, depressed, irritable, hopeless

0 = Not at all 1 = Several Day 2 = More than half of days 3 = Nearly every day

2. Little interest or pleasure in doing things

0 = Not at all 1 = Several Day 2 = More than half of days 3 = Nearly every day

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

0 = Not at all 1 = Several Day 2 = More than half of days 3 = Nearly every day

4. Poor appetite, weight loss, or overeating

0 = Not at all 1 = Several Day 2 = More than half of days 3 = Nearly every day

5. Feeling tired or having little energy

0 = Not at all 1 = Several Day 2 = More than half of days 3 = Nearly every day

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

0 = Not at all 1 = Several Day 2 = More than half of days 3 = Nearly every day

7. Trouble concentrating on things like schoolwork, reading or watching television

0 = Not at all 1 = Several Day 2 = More than half of days 3 = Nearly every day

8. Moving or speaking so slowly that other people could have noticed, or the opposite: being so fidgety or restless that you were moving around a lot more than usual

0 = Not at all 1 = Several Day 2 = More than half of days 3 = Nearly every day

9. Thoughts that you would be better off dead, or thoughts of hurting yourself in some way

0 = Not at all 1 = Several Day 2 = More than half of days 3 = Nearly every day

10. In the past year have you felt depressed or sad most days, even if you felt okay sometimes?

Yes No

11. 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? (circle one)

Not Difficult at all Somewhat difficult Very Difficult Extremely Difficult

12. Has there been a time in the last month when you have had serious thoughts about ending your life?

Yes No

13. Have you ever, in your whole life, tried to kill yourself or made a suicide attempt?

Yes No

14. Has there been any recent crisis or urgent visit(s) for mental health concerns?

Yes No

If yes, to where?

Primary Care Physician’s Office In-Patient Hospitalization Emergency Room Other

If Other, please specify:

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