Mental Health Review

Step 1 of 2

Contact Details

Home Address


Over the last two weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself, or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
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)
Thoughts that you would be better off dead, or of hurting yourself in some way

Severity Score

0-4 = None
5-9 = Mild
10-14 = Moderate
15-19 = Moderately severe
20-27 = Severe


If you have 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?