Online Mental Health Review Contact DetailsName First Name Surname Date Day Month Year Contact NumberHome Address Street Address Address Line 2 City Postcode QuestionnaireOver the last two 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 than half the days Nearly every day Feeling down, depressed, or hopeless Not at all Several days More than half the days Nearly every day Trouble falling or staying asleep, or sleeping too much Not at all Several days More than half the days Nearly every day Feeling tired or having little energy Not at all Several days More than half the days Nearly every day Poor appetite or overeating Not at all Several days More than 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 than half the days Nearly every day 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 Moving or speaking so slowly that other people could have noticed Not at all Several days More than half the days Nearly every day (Or the opposite—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 Not at all Several days More than half the days Nearly every day FinallyRegarding the questions above, if you checked off “Several days”, “More than half the days” or “Nearly every day”; how have these problems effected your ability to do your work, take care of things at home, or get along with other people?The problems I've checked off above… Have no effect on my ability to work, take care of things at home or get along with others Make it a bit difficult to work, take care of things at home and get along with others Make it quite difficult to work, take care of things at home and get along with others Make it extremely difficult to work, take care of things at home and get along with others
