FLCES MH Screener

Name:*

Last, First

DOB:*

MM/DD/YYYY

Over the last 2 weeks, on how many days have you been bothered by any of the following problems?

DEPRESSION SCREENER*

Rows	Not at all	Several Days	More than half the days	Nearly every day
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 over eating
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 Thoughts that you would be better off dead or of hurting yourself in some way

PHQ9 - Total Score

Type the above PHQ9 total score here:

ANXIETY SCREENER*

Rows	Not at all	Several Days	More than half the days	Nearly every day
Feeling nervous, anxious or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

GAD7 - Total Score

Type the above GAD7 total score here:

Today's Date:*

MM/DD/YYYY