Depression Review

Last Updated: 14/08/2020

Personal Details

First name *

Surname *

Date of birth *

Lifestyle

How many units of alcohol do you consume each week? *

Do you smoke? *

Never smoked

Ex smoker

Trivial (less than one cigarette per day)

Light (1-9 cigarettes per day)

Moderate (10-19 cigarettes per day)

Heavy (20-39 cigarettes per day)

Very heavy (40+ cigarettes per day)

Rolls own cigarettes

Smokes a pipe

Smokes cigars

Mood Review

If you are an immediate risk to yourself or others please stop here and seek urgent help. *

I am not an immediate risk to myself or others

Over the last 2 weeks, how often have you been bothered by little interest or pleasure in doing things? *

Not at all

Several days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you been bothered by feeling down, depressed or hopeless? *

Not at all

Several days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you been bothered by trouble falling or staying asleep or sleeping too much? *

Not at all

Several days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you been bothered by feeling tired or having little energy? *

Not at all

Several days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you been bothered by poor appetite or overeating? *

Not at all

Several days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you been bothered by 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

Over the last 2 weeks, how often have you been bothered by 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

Over the last 2 weeks, how often have you been bothered by moving or speaking so slowly that other people could have noticed or being so fidgety that you have been moving around a lot more than usual? *

Not at all

Several days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you been bothered by 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

Questions or Concerns

This is not for any urgent matters.

Do you have any questions or concerns?

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Depression Review

Further Information