Depression Screening Questionnaire

Mendelson Kornblum Physical Therapy

Short Form Depression Screening Questionnaire

Please check the boxes that apply to you in the last few weeks.
I am unable to do the things I used to doI feel hopeless about the futureI cannot make decisionsI feel sluggish or restlessI am gaining or losing weightI am tired for no reasonI am sleeping to much, or too littleI feel unhappyI become irritable or anxiousI think about dying or suicide

Mendelson Kornblum Physical Therapy has a Social-Worker-Counselor on staff to speak with you about the questions listed above. She can also provide information about community resources to help you deal with your physical or psychological concerns.

Would you like the Social Worker-Counselor to contact you at this time?
YesNo

Would you like information about the Social Work-Counseling Services available at this site?
YesNo

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