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780-809-1955 ext.1
5603 199 St
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Depression Questionnaire
Over the past 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things
(Required)
Not at all
Several days
More than half the days
Nearly every day
Feeling down, depressed, or hopeless
(Required)
Not at all
Several days
More than half the days
Nearly every day
Trouble falling or staying asleep, or sleeping too much
(Required)
Not at all
Several days
More than half the days
Nearly every day
Feeling tired or having little energy
(Required)
Not at all
Several days
More than half the days
Nearly every day
Poor appetite or overeating
(Required)
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
(Required)
Not at all
Several days
More than half the days
Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching TV
(Required)
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
(Required)
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
(Required)
Not at all
Several days
More than half the days
Nearly every day
Contact Information
** Please provide your full legal name as it appears on your driver’s license and you Alberta Health Care number.
First name
(Required)
Last name
(Required)
Alberta Health Care #
(Required)
Phone
This field is for validation purposes and should be left unchanged.
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About Elixir Medical Centres
Our Team
Medical Services
Women’s Health
Specialty Services
Third Party Services
For Patients
Clinic Policies
Health Education
Health Tips
Health Resources
Book An Appointment
Careers
Contact
780-809-1955 ext.1
5603 199 St