Mental Health Check-up
The following questions will help us determine a diagnosis for depression.
Please enter your Name.
*
First Name
Last Name
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
0
1
2
Nearly Every Day
3
0 is Not at all, 3 is Nearly Every Day
Feeling down, depressed, or hopeless...
*
Not at all
0
1
2
Nearly Every Day
3
0 is Not at all, 3 is Nearly Every Day
Trouble falling or staying asleep, or sleeping too much...
*
Not at all
0
1
2
Nearly Every Day
3
0 is Not at all, 3 is Nearly Every Day
Feeling tired or having little energy...
*
Not at all
0
1
2
Nearly Every Day
3
0 is Not at all, 3 is Nearly Every Day
Poor appetite or overeating...
*
Not at all
0
1
2
Nearly Every Day
3
0 is Not at all, 3 is Nearly Every Day
Feeling bad about yourself- or that you are a failure or have let yourself or your own family down...
*
Not at all
0
1
2
Nearly Every Day
3
0 is Not at all, 3 is Nearly Every Day
Trouble concentrating on things, such as reading the newspaper or watching television...
*
Not at all
0
1
2
Nearly Every Day
3
0 is Not at all, 3 is Nearly Every Day
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...
*
Not at all
0
1
2
Nearly Every Day
3
0 is Not at all, 3 is Nearly Every Day
Thoughts that you would be better of dead or of hurting yourself in some way...
*
Not at all
0
1
2
Nearly Every Day
3
0 is Not at all, 3 is Nearly Every Day
Your total score is:
This field will auto-calculate after answering all questions.
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The following questions will help us determine a diagnosis for anxiety.
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Feeling nervous, anxious, or on edge
*
Not at all
0
1
2
Nearly Every Day
3
0 is Not at all, 3 is Nearly Every Day
Not being able to stop or control worrying
*
Not at all
0
1
2
Nearly Every Day
3
0 is Not at all, 3 is Nearly Every Day
Worrying too much about different things
*
Not at all
0
1
2
Nearly Every Day
3
0 is Not at all, 3 is Nearly Every Day
Trouble relaxing
*
Not at all
0
1
2
Nearly Every Day
3
0 is Not at all, 3 is Nearly Every Day
Being so restless that it is hard to sit still
*
Not at all
0
1
2
Nearly Every Day
3
0 is Not at all, 3 is Nearly Every Day
Becoming easily annoyed or irritable
*
Not at all
0
1
2
Nearly Every Day
3
0 is Not at all, 3 is Nearly Every Day
Feeling afraid as if something awful might happen
*
Not at all
0
1
2
Nearly Every Day
3
0 is Not at all, 3 is Nearly Every Day
Your total score is:
This field will auto-calculate after answering all questions.
If you checked off any problems, how difficulty 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
0
1
2
Extremely difficult
3
0 is Not difficult at all, 3 is Extremely difficult
Submit
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