Depression and Anxiety Questionnaire

Depression

1. Do you feel sad?
Yes No Not sure
2. Have you lost interest in your usual activities?
Yes No Not sure
3 Have you experienced a weight change of 10% or more?
Yes No Not sure
4. Feel tired everyday?
Yes No Not sure
5. Difficulty falling asleep, staying asleep, or sleeping more than usual?
Yes No Not sure
6. Feeling slowed down or restless?
Yes No Not sure
7. Feeling helpless, hopeless, or worthless?
Yes No Not sure
8. Difficulty in concentrating or making decisions?
Yes No Not sure
9. Thoughts of not wanting to live?
Yes No Not sure
10. Feeling agitated or easily irritated?
Yes No Not sure
11. Isolating yourself?
Yes No Not sure

Anxiety Screening

1. Pounding heart or racing heart rate?
Yes No Not sure
2. Excessive sweating?
Yes No Not sure
3. Feeling shaking, hands trembling, or weak-kneed?
Yes No Not sure
4. Feeling shortness of breath or difficulty breathing?
Yes No Not sure
5. Digestive discomfort?
Yes No Not sure
6. Feeling detached from your body or surroundings?
Yes No Not sure
7. Feeling out of control?
Yes No Not sure
8. Numbness or tingling sensation?
Yes No Not sure
9. Chills or feeling flushed?
Yes No Not sure
10. Fear of dying?
Yes No Not sure
11. Excessive worry?
Yes No Not sure
12. Irritable, restless, or on-edge?
Yes No Not sure
13. Easily fatigued?
Yes No Not sure
14. Muscle tension?
Yes No Not sure
15. Difficulty concentrating?
Yes No Not sure
16. Unable to sleep well?
Yes No Not sure

Thank you for taking the time to fill out these forms.
Please click on the "Submit" button below if you would like to share your results with Valerie.

If you responded "yes" to 5 or more questions in either category, you may be experiencing depression and/or anxiety. You may want to consult with a counselor or physician.

If you submitted your phone number or email address, you will be contacted soon.