Depression 1 Week F/U

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Name*
Address*
MM slash DD slash YYYY
Gender*
Over the past two weeks, how often have you had little interest in doing the things you used to enjoy?*
Over the past two weeks, how often have you felt down, depressed, or hopeless?*
Over the past two weeks, how often have you had trouble falling or staying asleep, or sleeping too much?*
Over the past two weeks, how often have you felt tired, or had little energy?*
Over the past two weeks, how often have you had a poor appetite, or have over-eaten?*
Over the past two weeks, how often have you felt bad about yourself, that you are a failure, or that you have let your family down?*
Over the past two weeks, how often have you had trouble concentrating on things such as reading, or watching television?*
Over the past two weeks, how often have you been bothered by the following problem?: 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*
Over the past two weeks, how often have you had thoughts that you would be better off dead, or of hurting yourself*
Over the past two weeks, how often have you been bothered by feeling nervous, anxious, or on edge?*
Over the past two weeks, how often have you been bothered by not being able to stop or control worrying?*
Over the past two weeks, how often have you been bothered by worrying too much about different things?*
Over the past two weeks, how often have you been bothered by trouble relaxing?*
Over the past two weeks, how often have you been bothered by being so restless that it is hard to sit still?*
Since you started the medication, have you experienced any side effects?
Over the past two weeks, how often have you been bothered by becoming easily annoyed or irritable?*
Over the past two weeks, how often have you been bothered by feeling afraid as if something awful might happen?*
How bothersome were these side effects?
GoodpillRx is dedicated to helping our patients have access to quality, affordable medications, delivered straight to their door.
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