Please enter the following information by typing the information, clicking on the checkboxes or selecting from the "pop-up" lists.

You may make any changes and corrections to the form prior to sending it but once you click on the SEND INFORMATION button the information will be transmitted to our office.

What is your name?

What is your age? (please enter number of years)

Are you Male or Female ?

Have your ever been diagnosed by a doctor (psychiatrist, psychologist or other mental health professional) as having MAJOR DEPRESSION NO MAYBE YES (Click on the box for other choices).

Which of the following symptoms of DEPRESSION have you experienced during the last 2 weeks? (Click on the box after each question for other choices, please answer all.)

• Depressed mood most of the day, nearly every day NO YES
• Diminished interest or pleasure in almost all activities most of the day nearly every day NO YES
• Significant weight loss when not dieting or decrease or increase in appetite nearly every day NO YES
• Insomnia or excessive sleeping nearly every day NO YES
• Agitation or lack or activity nearly every day NO YES
• Fatigue or loss of energy nearly every day NO YES
• Feelings of worthlessness or excessive guilt nearly every day NO YES
• Diminished ability to think or concentrate nearly every day NO YES
• Recurrent thoughts of death (not just fear of dying) or thought of suicide NO YES

Do the above symptoms of depression cause you to miss days at work or to neglect other daily responsibilities? NO YES

Have you suffered the loss of a loved one or been severly injured within the last year? NO YES

Misuse of alcohol or drugs may cause most of the above symptoms of depression. Is this a possibility for you? NO YES

Some other medical disorders can also cause some of the above symptoms of depression. Have you been diagnosed with any major medical disorders, like heart disease, hypothyrodism, diabetes, AIDS, cancer, or severe infections? NO YES

Would you like to schedule an appointment to meet with one of our doctors? NO YES

If you would like to make an appointment, please enter the following:

Your phone number: (with area code please)

Your address:

Street # or box

City

Statezip

Thankyou for completing this form. Please check each of your responses. If you are satisfied with your answers then click on the SEND INFORMATION button below.

It may take a few moments to complete the send, please wait for the process to complete and only click the button one time.