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Date of birth

Over the last two weeks, how often have you been bothered by any of the folloing problems:
Not at all
Several days
More than half the days.
Nearly every day
Little interest or pleasure in doing things

Feelling down, depressed or hopeless

Trouble falling or staying asleep or sleeping too much

Feeling tired or having little energy

Poor appetite or overeating

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

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

Moving or speaking so slowly that other people could have noticed.  Or the oppossitte - being so fidgety or restless that you have been moving around a lot more than usual.

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



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 difficult at all 
Somewhat difficult   
Very difficult       
Extremely difficult