Depression Assessment Questionnaire

Name *

Date of Birth *

Address *

Postcode *

Telephone number *

Over the last two weeks, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things?

Not at all

Several days

More than half the days

Nearly every day

Feeling down, depressed, or hopeless?

Not at all

Several days

More than half the days

Nearly every day

Trouble falling or staying asleep, or sleeping too much?

Not at all

Several days

More than half the days

Nearly every day

Feeling tired or having little energy?

Not at all

Several days

More than half the days

Nearly every day

Poor appetite or overeating?

Not at all

Several days

More than half the days

Nearly every day

Feeling bad about yourself, or that you are a failure or have let yourself or your family down?

Not at all

Several days

More than half the days

Nearly every day

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

Not at all

Several days

More than half the days

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?

Not at all

Several days

More than half the days

Nearly every day

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

Not at all

Several days

More than half the days

Nearly every day

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

Not at all

Several days

More than half the days

Nearly every day

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