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Crossroads Behavioral Health Services
1003 Cottonwood Rd
Phone 641-782-8457
Fax 641-782-7048
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Gender:  *  
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
Over the last 2 weeks, how often have you been bothered by any of the following problems?
* 1. Little interest or pleasure in doing things
0 - Not at all   1 - Several days   2 - More than half the days  
3 - Nearly every day     
* 2. Feeling down, depressed or hopeless
0 - Not at all   1 - Several days   2 - More than half the days  
3 - Nearly every day     
* 3. Trouble falling asleep, staying asleep, or sleeping too much
0 - Not at all   1 - Several days   2 - More than half the days  
3 - Nearly every day     
* 4. Feeling tired or having little energy
0 - Not at all   1 - Several days   2 - More than half the days  
3 - Nearly every day     
* 5. Poor appetite or overeating
0 - Not at all   1 - Several days   2 - More than half the days  
3 - Nearly every day     
* 6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down
0 - Not at all   1 - Several days   2 - More than half the days  
3 - Nearly every day     
* 7. Trouble concentrating on things, such as reading the newspaper or watching television
0 - Not at all   1 - Several days   2 - More than half the days  
3 - Nearly every day     
* 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.
0 - Not at all   1 - Several days   2 - More than half the days  
3 - Nearly every day     
* 9. Thoughts that you would be better off dead or of hurting yourself in some way
0 - Not at all   1 - Several days   2 - More than half the days  
3 - Nearly every day     
Total Score:
* Please enter score from above:
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