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

How many anti-depressant prescription medications do you currently take or have tried in the past?

2-4

Not Sure

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