Hospital Anxiety and Depression Screening Questionnaire
Please complete this questionnaire to help us assess your current emotional well-being. Your responses will remain confidential and assist our healthcare team in providing the best care.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please read the following instructions before starting the questionnaire: Answer each question based on how you have been feeling over the past two weeks. There are no right or wrong answers.
Over the last two weeks, how often have you been bothered by any of the following problems?
*
Rows
Not at all
Several days
More than half the days
Nearly every day
Feeling nervous, anxious or on edge
1
2
3
4
Not being able to stop or control worrying
5
6
7
8
Worrying too much about different things
9
10
11
12
Trouble relaxing
13
14
15
16
Feeling down, depressed, or hopeless
17
18
19
20
Little interest or pleasure in doing things
21
22
23
24
Trouble falling or staying asleep, or sleeping too much
25
26
27
28
Feeling tired or having little energy
29
30
31
32
Poor appetite or overeating
33
34
35
36
Feeling bad about yourself – or that you are a failure or have let yourself or your family down
37
38
39
40
If you would like to provide any additional comments or concerns, please use the space below.
Submit Questionnaire
Should be Empty: