Personal Information

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Survey

Do you have feelings of hopelessness or sadness?

Yes No

Do you have a feeling of worthlessness or excessive guilt?

Yes No

Do you wake up in the middle of the night or early morning hours without being able to return to sleep?

Yes No

Do you have difficulty falling asleep?

Yes No

Do you have a loss of energy or seem to tire too easily?

Yes No

Is your sex drive decreased?

Yes No

Do you have difficulty concentrating?

Yes No

Have you lost interest in activities that usually give you pleasure?

Yes No

Do you have frequent thoughts of suicide or death?

Yes No