Please answer the following questions:
Full Name
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Email
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Phone
*
Date of birth
*
How did you hear about us? If from a provider (postcards, referral, etc), please list the provider and practice's name.
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I agree to receive SMS and Emails from Lunajoy
Text
Over the last 2 weeks, how often have you been bothered by any of the following problems? Please choose your answers.
Little interest or pleasure in doing things.
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Not at all
Several days
More than half the days
Nearly every day
Feeling down, depressed, or hopeless.
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Not at all
Several days
More than half the days
Nearly every day
Trouble falling or staying asleep, or sleeping too much.
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Not at all
Several days
More than half the days
Nearly every day
Feeling tired or having little energy.
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Not at all
Several days
More than half the days
Nearly every day
Poor appetite or overeating.
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Not at all
Several days
More than half the days
Nearly every day
Feeling bad about yourself – or that you are a failure or have let yourself or your family down.
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Not at all
Several days
More than half the days
Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television.
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Not at all
Several days
More than half the days
Nearly every day
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.
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Not at all
Several days
More than half the days
Nearly every day
Thoughts that you would be better off dead, or of hurting yourself in some way
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Not at all
Several days
More than half the days
Nearly every day
Feeling nervous, anxious, or on edge.
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Not at all
Several days
Over half the days
Nearly every day
Not being able to stop or control worrying.
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Not at all
Several days
Over half the days
Nearly every day
Worrying too much about different things.
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Not at all
Several days
Over half the days
Nearly every day
Trouble relaxing.
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Not at all
Several days
Over half the days
Nearly every day
Being so restless that it’s hard to sit still.
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Not at all
Several days
Over half the days
Nearly every day
Becoming easily annoyed or irritable.
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Not at all
Several days
Over half the days
Nearly every day
Feeling afraid as if something awful might happen.
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Not at all
Several days
Over half the days
Nearly every day
If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?
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Not difficult at all
Somewhat difficult
Very Difficult
Extremely Difficult
Submit
