Name

Address

Postcode

Date of Birth

Home Phone Number

Mobile Phone Number 

Questionnaire

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

1. Little interest or pleasure in doing things Not at allSeveral daysMore than half the daysNearly every day

2. Feeling down, depressed, or hopeless Not at allSeveral daysMore than half the daysNearly every day

3. Trouble falling or staying asleep, or sleeping too much Not at allSeveral daysMore than half the daysNearly every day

4. Poor appetite or overeating Not at allSeveral daysMore than half the daysNearly every day

5. Feeling bad about yourself, or that you are a failure or have let yourself or your family down Not at allSeveral daysMore than half the daysNearly every day

6. Trouble concentrating on things, such as reading the newspaper or watching television Not at allSeveral daysMore than half the daysNearly every day

7. 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 allSeveral daysMore than half the daysNearly every day

8. Thoughts that you would be better off dead, or of hurting yourself in some way Not at allSeveral daysMore than half the daysNearly every day

Finally

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 at allSeveral daysMore than half the daysNearly every day

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