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Last name:
Date of Birth:

DayMonthYear
Date
NHS number (if known):
Phone number:
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Health assessment questions

Over the last 2 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 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:
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?
Rate by scale

Please answer the following questions using the following scale 0 - never avoid it, 2- slightly avoid it, 4 - definitely avoid it, 6 - markedly avoid it, 8 - always avoid it
Social situations due to a fear of being embarrassed or making a fool of myself:
Certain situations because of a fear of having a panic attack or other distressing symptoms (such as loss of bladder control, vomiting or dizziness) :
Certain situations because of a fear of particular objects or activities (such as animals, heights, seeing blood, being in onfined spaces, driving or flying) :
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Health assessment questions

Rate by scale

Privacy protection / consent