Full Name Age Email Date

How often have you been bothered by feeling down, depressed, or hopeless in the last 2 weeks? Never Several days More than half the days Nearly everyday

How often have you had little interest or pleasure in doing things? Never Several days More than half the days Nearly everyday

How often have you felt nervous, anxious, or on edge? Never Several days More than half the days Nearly everyday

How often have you been unable to stop or control worrying? Never Several days More than half the days Nearly everyday

Do you have trouble sleeping or sleeping too much? No Sometimes Often

Have you felt bad about yourself, or that you are a failure or have let yourself or your family down? Never Sometimes Often

Is there anything else you want to share about your mental health?