Depression Screening Survey
About Yourself
1. What is your age?
2. Which gender do you identify with?
Male
Female
Transgender
Other
3. Have you had a child as a parent or by birth, in the last year?
Yes
No
4. Please select if you are currently being treated for any of the following diseases.
Substance usage
Cancer
Diabetes
Chronic pain
HIV
Psychosis
Other
5. What is your marital status?
Married
Living with partner
Widowed
Separated or divorced
Never married
6. What is your employment status?
Student
Full time
Part time
Unemployed and looking for a job
Unemployed and not looking for job
Retired
Screening
1. Thinking the last two weeks, please rate the following situations:
Not At All
Several Days
Over Half The Days
Nearly Every Day
No interest in doing things
1
2
3
4
Feeling down or hopeless
5
6
7
8
Difficulties with sleeping
9
10
11
12
Sleeping too much
13
14
15
16
Feeling exhausted
17
18
19
20
Poor appetite or overeating
21
22
23
24
Feeling miserable
25
26
27
28
Feeling like doing everything wrong
29
30
31
32
Difficulties with concentration
33
34
35
36
Very slow or fast actions
37
38
39
40
Thinking about being dead
41
42
43
44
2. If you had any of the above situations, have these problems made it difficult for you to work, take care of things at home or stay in touch with other people?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
3. Have you ever had unusual out-of-control behaviors for a week or more?
Never
Over 6 months ago
In the past 6 months
4. Have you ever hurt someone because of irritable mood or excessive amount of anger for a week or more?
Never
Over 6 months ago
In the past 6 months
5. Have you ever been diagnosed with a mental health condition by a professional?
Yes
No
6. Have you ever received treatment/support for a mental health problem?
Yes
No
7. Do you have any close blood relatives who had mental illnesses?
Yes
No
Submit
Should be Empty: