Tinnitus and hyperacusis therapy specialist unit

Depression

Name of the patient:

Your Email Address:

Please type the email address that this form needs to be sent to.
This is often the email address of your clinician who asked you to complete this form.

For each question please select one number based on how you are feeling now.

Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use “✓” to indicate your answer)	Several Days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things	1	2	3
2. Feeling down, depressed, or hopeless	1	2	3
3. Trouble falling or staying asleep, or sleeping too much	1	2	3
4. Feeling tired or having little energy	1	2	3
5. Poor appetite or overeating	1	2	3
6. Feeling bad about yourself “” or that you are a failure or have let yourself or your family down	1	2	3
7. Trouble concentrating on things, such as reading the newspaper or watching television	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	1	2	3
9. Thoughts that you would be better off dead or of hurting yourself in some way	1	2	3

For Hearing Healthcare Professionals