Have You Heard Someone Say:

  •  Life isn't worth living
  •  My family would be better off without me
  •  Next time I'll take enough pills to do the job right
  • Take my (prized collection, valuables) - I don't need this       stuff anymore
  •  I won't be around to deal with that
  •  You'll be sorry when I'm gone
  •  I won't be in your way much longer
  •  I just can't deal with everything -- life's too hard
  •  Nobody understands me -- nobody feels the way I do
  •  There's nothing I can do to make it better
  •  I'd be better off dead
  •  I feel like there is no way out

Have You Observed:

  •  Getting affairs in order (paying off debts, changing a will)
  •  Giving away articles of either personal or monetary value
  •  Signs of planning a suicide such as obtaining a weapon or       writing a suicide note

Depression Questionnaire

Have you noticed the following signs of depression:

  •  Depressed mood
  •  Change in sleeping patterns (too much/little, disturbances)
  •  Change in weight or appetite
  •  Speaking and/or moving with unusual speed or slowness
  •  Loss of interest or pleasure in usual activities
  •  Withdrawal from family and friends
  •  Fatigue or loss of energy
  •  Diminished ability to think or concentrate, slowed thinking       or indecisiveness
  •  Feelings of worthlessness, self-reproach, or guilt
  •  Thoughts of death, suicide, or wishes to be dead

If depression seems possible, have you also noticed:

  •  Extreme anxiety, agitation, irritability or risky behavior
  •  Racing thoughts, excessive energy, reduced need for sleep
  •  Excessive drug and/or alcohol use or abuse
  •  Neglect of physical health
  •  Feelings of hopelessness

Download This Questionnaire

Created by Screening for Mental Health, Inc. with educational facts adapted from material provided by National Depression Screeniing Day (NDSD)
sponsors: the American Foundation for Suicide Prevention, (AFSP) and the American College Health Association (ACHA). Consultants: Ross J. Baldeddarini, MD amd Kay R. Jamison, PhD