Surveyy Azadi Health advancing mental health for BIPOC populations

Patient Depression Questionnaire

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Step 1 of 17

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Includes mental health.

World Health Organization(WHO) research shows 1 out of 4 people will experience a common mental disorder like anxiety and depression in their lifetime.

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User ID

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Clinician

Name(Required)

Date(Required)

MM slash DD slash YYYY

How Often You Have been bothered by each of the following symptoms during past two weeks? For each symptom put an "X" in the box beneath the answer that best describes how you have been feeling.

1. Feeling Down, depressed, irritable, or hopeless(Required)

Question 01/13

Feeling Down, depressed, irritable, or hopeless

Not At All

Several Days

More Than Half the Days

Nearly Every Day

2. Little interest or pleasure in doing things?(Required)

Question 02/13

Little interest or pleasure in doing things?

Not At All

Several Days

More Than Half the Days

Nearly Every Day

3. Trouble falling asleep, staying asleep, or sleeping too much?(Required)

Question 03/13

Trouble falling asleep, staying asleep, or sleeping too much?

Not At All

Several Days

More Than Half the Days

Nearly Every Day

4. Poor appetite, weight loss, or overeating?(Required)

Question 04/13

Poor appetite, weight loss, or overeating?

Not At All

Several Days

More Than Half the Days

Nearly Every Day

5. Feeling tired or having little energy?(Required)

Question 05/13

Feeling tired or having little energy?

Not At All

Several Days

More Than Half the Days

Nearly Every Day

6. Feeling bad about yourself - or feeling you are a failure, or that you have let yourself or your family down?(Required)

Question 06/13

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

Not At All

Several Days

More Than Half the Days

Nearly Every Day

7. Trouble concentrating on things like school work, reading, or watching TV?(Required)

Question 07/13

Trouble concentrating on things like school work, reading, or watching TV?

Not At All

Several Days

More Than Half the Days

Nearly Every Day

8. Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you were moving around a lot more than usual?(Required)

Question 08/13

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

Not At All

Several Days

More Than Half the Days

Nearly Every Day

9. Thoughts that you would be better off dead, or of hurting yourself in some way?(Required)

Question 09/13

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

10. In the past years have you felt depressed or sad most days, even if you felt okay sometimes?(Required)

Question 10/13

In the past years have you felt depressed or sad most days, even if you felt okay sometimes?

Yes

11. If you are experiencing any of the problems on this form, how difficult have these problems made it for you to do the work, take care of things at home or get along with other people?(Required)

Question 11/13

If you are experiencing any of the problems on this form, how difficult have these problems made it for you to do the work, take care of things at home or get along with other people?

Not Difficult at all

Somewhat Difficult

Very Difficult

Extremely Difficult

12. Has there been a time in the past month when you have had serious thoughts about ending your life?(Required)

Question 12/13

Has there been a time in the past month when you have had serious thoughts about ending your life?

Yes

13. Have you ever in your whole life, tried to kill yourself or made a sucide attempt?(Required)

Question 13/13

Have you ever in your whole life, tried to kill yourself or made a sucide attempt?

Yes

Phone

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Good Health

Includes mental health.

You are not alone

Learn skills to reduce stress

speak to your community

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