Chronic Illness Patient Mental Health Screening Form
Patient Information
Full Name
Date of Birth
Gender
Female
Male
Other
Prefer not to say
Primary Chronic Illness Diagnosis
Mental Health Screening
Over the past 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless?
Not at all
Several days
More than half the days
Nearly every day
Over the past 2 weeks, how often have you been bothered by little interest or pleasure in doing things?
Not at all
Several days
More than half the days
Nearly every day
In general, how would you describe your stress level?
Low
Moderate
High
Do you often feel anxious or worried?
Yes
No
Have you had trouble falling or staying asleep, or sleeping too much in the past 2 weeks?
Not at all
Several days
More than half the days
Nearly every day
Do you have someone you can talk to about your feelings?
Yes
No
Additional Comments
Is there anything else you would like to share with your healthcare provider?