Mood Questionnaire

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Name* This field is required.
First Name
Last Name
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Date* This field is required.
Date
Month
Day
Year
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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Area Code
Phone Number
5
Please read the following group of statements carefully, and then pick out the one statement in each group that best describes the way you have been feeling during the past two weeks, including today. If several statements in the group seem to apply equally well, select the highest number for that group.
6
Over the last 2 weeks, how often have you been bothered by any of the following problems?* This field is required.
Not At All
Several Days
More than half the days
Nearly Everyday
1. Little interest or pleasure in doing things
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
2. Feeling down, depressed, or hopeless
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
3. Trouble falling or staying asleep, or sleeping too much
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Row 2, Column 1
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Row 2, Column 3
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
Not At All
Row 0, Column 0
Several Days
Row 0, Column 1
More than half the days
Row 0, Column 2
Nearly Everyday
Row 0, Column 3
Not At All
Row 1, Column 0
Several Days
Row 1, Column 1
More than half the days
Row 1, Column 2
Nearly Everyday
Row 1, Column 3
Not At All
Row 2, Column 0
Several Days
Row 2, Column 1
More than half the days
Row 2, Column 2
Nearly Everyday
Row 2, Column 3
1 of 3
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Over the last 2 weeks, how often have you been bothered by any of the following problems?* This field is required.
Not At All
Several Days
More than half the days
Nearly Everyday
4. Feeling tired or having little energy
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Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
5. Poor appetite or overeating
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Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
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Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
Not At All
Row 0, Column 0
Several Days
Row 0, Column 1
More than half the days
Row 0, Column 2
Nearly Everyday
Row 0, Column 3
Not At All
Row 1, Column 0
Several Days
Row 1, Column 1
More than half the days
Row 1, Column 2
Nearly Everyday
Row 1, Column 3
Not At All
Row 2, Column 0
Several Days
Row 2, Column 1
More than half the days
Row 2, Column 2
Nearly Everyday
Row 2, Column 3
1 of 3
8
Over the last 2 weeks, how often have you been bothered by any of the following problems?* This field is required.
Not At All
Several Days
More than half the days
Nearly Everyday
7. Trouble concentrating on things, such as reading the newspaper or watching television
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
7. Trouble concentrating on things, such as reading the newspaper or watching television
Not At All
Row 0, Column 0
Several Days
Row 0, Column 1
More than half the days
Row 0, Column 2
Nearly Everyday
Row 0, Column 3
9
Over the last 2 weeks, how often have you been bothered by any of the following problems?* This field is required.
Not At All
Several Days
More than half the days
Nearly Everyday
8. 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.
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
8. 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
Row 0, Column 0
Several Days
Row 0, Column 1
More than half the days
Row 0, Column 2
Nearly Everyday
Row 0, Column 3
10
Over the last 2 weeks, how often have you been bothered by any of the following problems?* This field is required.
Not At All
Several Days
More than half the days
Nearly Everyday
9. Thoughts that you would be better off dead or of hurting yourself in some way
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
9. Thoughts that you would be better off dead or of hurting yourself in some way
Not At All
Row 0, Column 0
Several Days
Row 0, Column 1
More than half the days
Row 0, Column 2
Nearly Everyday
Row 0, Column 3
11
Over the last 2 weeks, how often have you been bothered by any of the following problems?* This field is required.
Not At All
Several Days
More than half the days
Nearly Everyday
10. Feeling nervous, anxious, or on edge
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Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
10. Feeling nervous, anxious, or on edge
Not At All
Row 0, Column 0
Several Days
Row 0, Column 1
More than half the days
Row 0, Column 2
Nearly Everyday
Row 0, Column 3
12
Over the last 2 weeks, how often have you been bothered by any of the following problems?* This field is required.
Not At All
Several Days
More than half the days
Nearly Everyday
11. Not being able to stop or control worrying
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Row 0, Column 2
Row 0, Column 3
11. Not being able to stop or control worrying
Not At All
Row 0, Column 0
Several Days
Row 0, Column 1
More than half the days
Row 0, Column 2
Nearly Everyday
Row 0, Column 3
13
Over the last 2 weeks, how often have you been bothered by any of the following problems?* This field is required.
Not At All
Several Days
More than half the days
Nearly Everyday
12. Worrying too much about different things
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Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
12. Worrying too much about different things
Not At All
Row 0, Column 0
Several Days
Row 0, Column 1
More than half the days
Row 0, Column 2
Nearly Everyday
Row 0, Column 3
14
Over the last 2 weeks, how often have you been bothered by any of the following problems?* This field is required.
Not At All
Several Days
More than half the days
Nearly Everyday
13. Trouble relaxing
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Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
13. Trouble relaxing
Not At All
Row 0, Column 0
Several Days
Row 0, Column 1
More than half the days
Row 0, Column 2
Nearly Everyday
Row 0, Column 3
15
Over the last 2 weeks, how often have you been bothered by any of the following problems?* This field is required.
Not At All
Several Days
More than half the days
Nearly Everyday
14. Being so restless that it is hard to sit still
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
14. Being so restless that it is hard to sit still
Not At All
Row 0, Column 0
Several Days
Row 0, Column 1
More than half the days
Row 0, Column 2
Nearly Everyday
Row 0, Column 3
16
Over the last 2 weeks, how often have you been bothered by any of the following problems?* This field is required.
Not At All
Several Days
More than half the days
Nearly Everyday
15. Becoming easily annoyed or irritable
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Row 0, Column 2
Row 0, Column 3
15. Becoming easily annoyed or irritable
Not At All
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Several Days
Row 0, Column 1
More than half the days
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Nearly Everyday
Row 0, Column 3
17
Over the last 2 weeks, how often have you been bothered by any of the following problems?* This field is required.
Not At All
Several Days
More than half the days
Nearly Everyday
16. Feeling afraid as if something awful might happen
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Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
16. Feeling afraid as if something awful might happen
Not At All
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Several Days
Row 0, Column 1
More than half the days
Row 0, Column 2
Nearly Everyday
Row 0, Column 3
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If you 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?* This field is required.
Not At All
Several Days
More than half the days
Nearly Everyday
Check One
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Row 0, Column 2
Row 0, Column 3
Check One
Not At All
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Several Days
Row 0, Column 1
More than half the days
Row 0, Column 2
Nearly Everyday
Row 0, Column 3
19
PHQ-9 Score (0-4 Minimal) (5-9 Mild) (10-14 Moderate) (15-19 Moderately-Severe) (20+ Severe)
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GAD-7 Score (0-5 Minimal) (6-10 Mild) (11-15 Moderate) (16-21 Severe)
Should be Empty: