Depression Care Management


Over the last 2 weeks. How often have you been bothered by the following problems? Not at all Several days More than half the days Nearly every day
1 Little interest or pleasure in doing things 0 1 2 3
2 Feeling down, depressed or hopeless 0 1 2 3
3 Trouble falling or staying asleep, or sleeping too much 0 1 2 3
4 Feeling tired or having little energy 0 1 2 3
5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourself - or that you are a failure or have let yourself or your family down 0 1 2 3
7 Trouble concentrating on things, such as reading the newspaper or watching TV 0 1 2 3
8 Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual 0 1 2 3
9 Thoughts that you would be better off dead, or of hurting yourself in some way 0 1 2 3
      + + =
10 If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult
  • If you have thoughts of harming yourself, call your doctor immediately.
  • Print this form and show it to your doctor. (To print, click on the Printer image on the toolbar at the top of this screen.)
  • If you have a score of 12 or more, please contact your physician to see if treatment for depression would be good for you.
  • If you are being treated for depression, get into a depression care management program for best results.
  • If you score less than 12, take the questionnaire again in a week. If you have increased to a score of 12 or above, please contact your physician to see if treatment for depression would be good for you.

Medical Disclaimer
This checklist is intended only for the purpose of identifying symptoms of depression and is not designed to provide a diagnosis or treatment. Only a doctor or other qualified healthcare professional can make a diagnosis of depression or determine a treatment plan.

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