First Name
*
Last Name
*
Date of birth
*
Email
*
Phone
*
Address
City
State
Zip Code
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
0 - Not At All
1- Several Days
2- More Than Half The Days
3- Nearly Ever Day
2. Feeling down, depressed, or hopeless
0 - Not at all
1 - Several Days
2 - More Than Half The Days
3 - Nearly Every Day
3. Trouble falling or staying asleep, or sleeping too much
0 - Not at all
1 - Several Days
2 - More Than Half The Days
3 - Nearly Every Day
4. Feeling tired or having little energy
0 - Not at all
1 - Several Days
2 - More Than Half The Days
3 - Nearly Every Day
5. Poor appetite or overeating
0 - Not at all
1 - Several Days
2 - More Than Half The Days
3 - Nearly Every Day
6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down
0 - Not at all
1 - Several Days
2 - More Than Half The Days
3 - Nearly Every Day
7. Trouble concentrating on things, such as reading the newspaper or watching television
0 - Not at all
1 - Several Days
2 - More Than Half The Days
3 - Nearly Every Day
8. Moving or speaking so slowly that other people could notice. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual
0 - Not at all
1 - Several Days
2 - More Than Half The Days
3 - Nearly Every Day
9. Thoughts that you would be better off dead, or of hurting yourself
0 - Not at all
1 - Several Days
2 - More Than Half The Days
3 - Nearly Every Day
Would you be interested in learning more about a safe, effective, non-drug treatment for depression?
Yes
No
How many anti-depressant prescription medications do you currently take or have tried in the past?
0
1
2-4
5+
Not Sure
Finished