Depression Screening Survey
About Yourself
Please answer every question honestly there is absolutely NO JUDGMENT HERE! This is only for the sole purpose of testing my product. Thank you for participating.*** Due to a large number of submissions we may contact you via email for more information to finalize our test group. Thank you.
1. Name
2.Best Contact Info
3. Email
example@example.com
4. What is your age? Date of Birth?
5. Which gender do you identify with?
Male
Female
Transgender
Other
6.Have you had a child as a parent or by birth, in the last year?
Yes
No
8. What is your marital status?
Married
Living with partner
Widowed
Separated or divorced
Never married
9. Please select if you are currently being treated for any of the following diseases.
Substance usage
Cancer
Diabetes
Chronic pain
HIV
Psychosis
Other
10. What is your employment status?
Student
Full time
Part time
Unemployed and looking for a job
Unemployed and not looking for job
Retired
Screening
1. Thinking the last two weeks, please rate the following situations:
Not At All
Several Days
Over Half The Days
Nearly Every Day
No interest in doing things
Feeling down or hopeless
Difficulties with sleeping
Sleeping too much
Feeling exhausted
Poor appetite or overeating
Feeling miserable
Feeling like doing everything wrong
Difficulties with concentration
Very slow or fast actions
Thinking about being dead
2. If you had any of the above situations, have these problems made it difficult for you to work, take care of things at home or stay in touch with other people?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
3. Have you ever had unusual out-of-control behaviors for a week or more?
Never
Over 6 months ago
In the past 6 months
4. Have you ever hurt someone because of irritable mood or excessive amount of anger for a week or more?
Never
Over 6 months ago
In the past 6 months
5. Have you ever been diagnosed with a mental health condition by a professional?
Yes
No
6. Have you ever received treatment/support for a mental health problem?
Yes
No
7. Do you have any close blood relatives who had mental illnesses?
Yes
No
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8. What medications are you currently taking?
9.Please describe when and how you started feeling depressed/anxious? Trigger/Trauma?
10. Tell me about your acheivments/ completed goals/ awards/ astonishments?
11. Anything else you would like to add about yourself?
Submit
Should be Empty: