Please complete this form if you were directed by our clinic to do so

Choose your medical practice Name * Date of Birth *

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

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 yourself or your family down Trouble Concentrating on things such as reading the newspaper or watching TV Moving or speaking slowly that other people could have noticed or the opposite- being so figety or restless that you have been moving around a lot more than usual * Thoughts that you would be better off dead or of hurting yourself If you checked off any problems how difficult have the problems made it for you to do your work, take care of things at home or get along with other people