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Mental Health Questionnaire

Mental Health Questionnaire

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Depression Questionnaire

Do you have Little interest or pleasure in doing things on a daily basis?
On a daily basis do you find yourself feeling down, depressed or hopeless?
Do you feel like your daily mood causes you trouble falling asleep, staying asleep, or sleeping too much?
In your opinion do you think you have low energy on a daily basis?
Does your mood sometimes cause poor appetite or overeating?
Do you Feel bad about yourself – or that you’re a failure and have let yourself and your family down on a regular basis?
Do you have thoughts that you would be better off dead or of hurting yourself in some way?
Which of these do you think describes your daily depression most accurately?

Anxiety Questionnaire

Do you Feel nervous, anxious or on edge on a daily basis?
Do you have trouble with being able to stop or control worrying?
Do you have issues worrying about too many different things at the same time?
Do you feel you have trouble relaxing on a daily basis?
Have you ever been so restless that it is hard to sit still?
Do you feel that your anxiety causes you headaches?
Are you easily annoyed or irritable?
Do you feel afraid something awful might happen on a daily basis?
Which of these do you feel describes your daily anxiety?

Last few questions (Don’t worry everything is confidential)

1: Are you currently abusing illicit substances?
2: Do you smoke cigarettes?
3: Do you currently suffer from Diabetes or Heart Disease?
4: Have you had a physical exam in the last 12 Months?
5: Is there anything you feel that our providers should know about prior to prescribing medications for your Anxiety or Depression?
We will contact you using this name.
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