Depression Screening Form - MD

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Depression Screening

Depression Screening

Screening for depression involves asking a series of questions to assess a person's mood, emotions, and overall mental well-being. Here are 10 mental health screening questions to help determine if someone may be experiencing depression:

14Questions

1
Please enter your full name:* This field is required.
First Name
Last Name
2
What's your email?* This field is required.
example@example.com
3
What's your phone number?* This field is required.
Please enter a valid phone number.
4
What type of insurance do you have?* This field is required.
Medicaid
Cigna
CareFirst
Blue Cross Blue Shield
United Healthcare
Aetna
Kaiser Permanente
Humana
Other
5
Over the past two weeks, have you often felt sad, down, or hopeless?* This field is required.This question assesses whether the individual has been experiencing persistent low mood.
Never
Sometimes
All the time
6
Have you lost interest or pleasure in activities you used to enjoy?* This field is required.This question explores anhedonia, the loss of interest in previously enjoyable activities, which is a common symptom of depression.
Never
Sometimes
All the time
7
Have you noticed significant changes in your appetite or weight recently?* This field is required.Weight loss or gain without intentional dieting can be a sign of depression.
Never
Sometimes
All the time
8
Are you experiencing disruptions in your sleep patterns, such as trouble falling asleep, staying asleep, or oversleeping?* This field is required.Sleep disturbances, including insomnia or hypersomnia, can be indicative of depression.
Never
Sometimes
All the time
9
Have you been feeling excessively guilty or worthless?* This field is required.Feelings of excessive guilt or worthlessness are emotional signs of depression.
Never
Sometimes
All the time
10
Is it difficult for you to concentrate, make decisions, or think clearly?* This field is required.Cognitive difficulties, such as poor concentration, are often associated with depression.
Never
Sometimes
All the time
11
Have you experienced physical symptoms like aches, pains, or digestive problems without a clear medical cause?* This field is required.Depression can manifest as physical symptoms, so it's important to inquire about these.
Never
Sometimes
All the time
12
Do you have thoughts of death, self-harm, or suicide?* This field is required.Assessing for suicidal ideation is crucial when screening for depression, as it indicates the need for immediate intervention.
Never
Sometimes
All the time
13
If you're having thoughts of death, self-harm, or suicide right now, call or text 9-8-8 to contact the nation-wide 24-hour crisis intervention and supportive counseling hotline for SUICIDE. Maryland Crisis Teams* This field is required.
Got It
14
Your Score0 – 4 points: Low Likelihood of Depression 5 – 9 points: Mild to Moderate Symptoms 10 – 16 points: High Likelihood of Depression
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