Please only complete this form if someone from the team as asked you to do so.

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Over the last 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things:

0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day

Feeling down, depressed, or hopeless:

0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day

Trouble falling or staying asleep, or sleeping too much:

0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day

Feeling tired or having little energy:

0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day

Poor appetite or overeating:

0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day

Feeling bad about yourself – or that you are a failure or have let yourself or your family down:

0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day

Trouble concentrating on things, such as reading the newspaper or watching television:

0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day

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:

0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day

Thoughts that you would be better off dead, or of hurting yourself in some way.:

0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day

Add your scores for the above section and record here:

If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at allSomewhat difficultVery DifficultExtremely Difficult

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Feeling nervous, anxious, or on edge:

0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day

Not being able to stop or control worrying:

0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day

Worrying too much about different things:

0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day

Trouble relaxing:

0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day

Being so restless that it’s hard to sit still:

0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day

Becoming easily annoyed or irritable:

0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day

Feeling afraid as if something awful might happen:

0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day

Add your scores for the above section and record here:

If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at allSomewhat difficultVery DifficultExtremely Difficult

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