The form on this page is an easy to use patient questionnaire has been validated for use in Primary Care.
It is used by your doctor to monitor the severity of depression and response to treatment.
It can also be used to make a tentative diagnosis of depression.
If you are recurrently experiencing the symptoms in the questionnaire, this may indicate signs of depression. If you have concerns you may be suffering with depression please book an appointment with a doctor to discuss this further as there is often much that can be done to help.
If you are having thoughts of harming yourself and need to speak to somone out of hours as an emergency, please call Cumbria Health on Call on 03000 247 247, for help
Over the last two weeks, how often have you been bothered by any of the following problems?
Information submitted through secure forms is used only for the purposes of processing your request. We may
be in touch with you in relation to the information submitted.
All Information submitted through secure forms is secured with a private key and is accessed over a secure
connection by nominated staff. We have a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
I consent to my information being used for the purposes described above and wish to submit this online form to
Haggs Lane, Cartmel, Grange-over-Sands, Cumbria, LA11 6PH.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.