Depression Self Assessment Depression Self-Assessment Personal DetailsFull Name Date of Birth DD slash MM slash YYYY Email Address Phone NumberSecurity QuestionIn which month did you last see a doctor/nurse at this surgery?Do you take any prescribed medication? Can you tell me what they are?Have you had an operation in hospital? Can you remember when and what for?May be used to identify youAnswer Patient Health Questionnaire (PHQ-9)Over the last 2 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 then half the days Nearly every day Feeling down, depressed, or hopeless? Not at all Several Days More then half the days Nearly every day Trouble falling or staying asleep, or sleeping too much? Not at all Several Days More then half the days Nearly every day Feeling tired or having little energy? Not at all Several Days More then half the days Nearly every day Poor appetite or overeating? Not at all Several Days More then 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 then half the days Nearly every day Trouble concentrating on things, such as reading the newspaper or watching television? Not at all Several Days More then half the days Nearly every day Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual? Not at all Several Days More then half the days Nearly every day Thoughts that you would be better off dead, or thoughts of hurting yourself in some way? Not at all Several Days More then half the days Nearly 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? Not difficult at all Somewhat difficult Very difficult Extremely difficult GAD-7 AssessmentOver the last two weeks how often have you been bothered by the following problems?Feeling nervous, anxious, or on edge Not at all Several Days More then half the days Nearly every day Not being able to stop or control worrying Not at all Several Days More then half the days Nearly every day Worrying too much about different things Not at all Several Days More then half the days Nearly every day Trouble relaxing Not at all Several Days More then half the days Nearly every day Being so restless that it is hard to sit still Not at all Several Days More then half the days Nearly every day Becoming easily annoyed or irritable Not at all Several Days More then half the days Nearly every day Feeling afraid, as if something awful might happen Not at all Several Days More then half the days Nearly 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? Not difficult at all Somewhat difficult Very difficult Extremely difficult Privacy Consent I consent to the practice collecting and storing my data from this form.This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.
