Depression & Mental Health

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

Useful Mental Health Websites:

www.rcpsych.ac.uk

www.youngminds.org.uk

www.minded.org.uk

http://www.hypnotherapy-directory.org.uk/articles/anxiety.html

1Depression & Mental Health

Name

Date of Birth

Address

Postcode

Phone 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 Please Choose...Not at allSeveral daysMore than half the daysNearly every day

Feeling down, depressed, or hopeless Please Choose...Not at allSeveral daysMore than half the daysNearly every day

Trouble falling or staying asleep, or sleeping too much Please Choose...Not at allSeveral daysMore than half the daysNearly every day

Feeling tired or having little energy Please Choose...Not at allSeveral daysMore than half the daysNearly every day

Poor appetite or overeating Please Choose...Not at allSeveral daysMore than half the daysNearly every day

Feeling bad about yourself, or that you are a failure or have let yourself or your family down Please Choose...Not at allSeveral daysMore than half the daysNearly every day

Trouble concentrating on things, such as reading the newspaper or watching television Please Choose...Not at allSeveral daysMore than half the daysNearly 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 Please Choose...Not at allSeveral daysMore than half the daysNearly every day

Thoughts that you would be better off dead, or of hurting yourself in some way Please Choose...Not at allSeveral daysMore than half the daysNearly every day

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? Please Choose...Not difficult at allSomewhat difficultVery difficultExtremely difficult

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