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Non-Disclosure
New Patient Information
No Cost Programs
Patient Feedback
Our Services
General Medicine
Pediatrics
Reproductive Health
Geriatric Care
Dermatology
Orthopedics
Weight Management
Urgent Care
Employer Services
Nursing Home & Assisted Living Services
Patients
Patient Forms
Medication Pricing
Patient Portal
Sliding Scale Application
Billing & FAQ
Prescription Assistance
Order Supplements
Mental Health
ADD/ADHD Treatment
Addiction
Anxiety
Assessments
Athletes
Counseling Services
Counselors
Court Mandated Therapy
Depression
Eating Disorders
Evidence-Based Therapy Practices
Family and Children
Groups and Classes
The YFMC Blog
Locations
Cape Girardeau
Perryville
Menu
About
Non-Disclosure
New Patient Information
No Cost Programs
Patient Feedback
Our Services
General Medicine
Pediatrics
Reproductive Health
Geriatric Care
Dermatology
Orthopedics
Weight Management
Urgent Care
Employer Services
Nursing Home & Assisted Living Services
Patients
Patient Forms
Medication Pricing
Patient Portal
Sliding Scale Application
Billing & FAQ
Prescription Assistance
Order Supplements
Mental Health
ADD/ADHD Treatment
Addiction
Anxiety
Assessments
Athletes
Counseling Services
Counselors
Court Mandated Therapy
Depression
Eating Disorders
Evidence-Based Therapy Practices
Family and Children
Groups and Classes
The YFMC Blog
Locations
Cape Girardeau
Perryville
Schedule Appointment
Beck’s Depression Inventory
Please complete the following form.
Please complete the details below and then click on Submit and we'll be in contact.
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*
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First Name
*
Last Name
*
Phone Number
*
Email Address
*
1. Do you feel sad?
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0. I do not feel sad
1. I feel sad
2. I am sad all the time and I can’t snap out of it.
3. I am so sad and unhappy that I can’t stand it.
2. How do you feel about the future?
*
0. I am not particularly discouraged about the future.
1. I feel discouraged about the future.
2. I feel I have nothing to look forward to.
3. I feel the future is hopeless and that things cannot improve.
3. Do you feel like a failure?
*
0. I do not feel like a failure.
1. I feel I have failed more than the average person.
2. As I look back on my life, all I can see is a lot of failures.
3. I feel I am a complete failure as a person.
4. Do you enjoy things as usual?
*
0. I get as much satisfaction out of things as I used to.
1. I don’t enjoy things the way I used to.
2. I don’t get real satisfaction out of anything anymore.
3. I am dissatisfied or bored with everything.
5. How often do you feel guilty?
*
0. I don’t feel particularly guilty
1. I feel guilty a good part of the time.
2. I feel quite guilty most of the time.
3. I feel guilty all of the time.
6. Do you feel like you are being punished?
*
0. I don’t feel I am being punished.
1. I feel I may be punished.
2. I expect to be punished.
3. I feel I am being punished.
7. Are you disappointed in yourself?
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0. I don’t feel disappointed in myself.
1. I am disappointed in myself.
2. I am disgusted with myself.
3. I hate myself.
8. Do you blame yourself?
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0. I don’t feel I am any worse than anybody else.
1. I am critical of myself for my weaknesses or mistakes.
2. I blame myself all the time for my faults.
3. I blame myself for everything bad that happens.
9. Do you have thoughts of killing yourself?
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0. I don’t have any thoughts of killing myself.
1. I have thoughts of killing myself, but I would not carry them out.
2. I would like to kill myself.
3. I would kill myself if I had the chance.
10. Are you crying more or less than usual?
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0. I don’t cry any more than usual.
1. I cry more now than I used to.
2. I cry all the time now.
3. I used to be able to cry, but now I can’t cry even though I want to.
11. Do you feel irritated more easily?
*
0. I am no more irritated by things than I ever was.
1. I am slightly more irritated now than usual.
2. I am quite annoyed or irritated a good deal of the time.
3. I feel irritated all the time.
12. Are you interested in being around others?
*
0. I have not lost interest in other people.
1. I am less interested in other people than I used to be.
2. I have lost most of my interest in other people.
3. I have lost all of my interest in other people.
13. Can you make decisions easily?
*
0. I make decisions about as well as I ever could.
1. I put off making decisions more than I used to.
2. I have greater difficulty in making decisions more than I used to.
3. I can’t make decisions at all anymore.
14. How do you feel about your appearance?
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0. I don’t feel that I look any worse than I used to.
1. I am worried that I am looking old or unattractive.
2. I feel there are permanent changes in my appearance that make me look unattractive
3. I believe that I look ugly.
15. Are you able to work?
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0. I can work about as well as before.
1. It takes an extra effort to get started at doing something.
2. I have to push myself very hard to do anything.
3. I can’t do any work at all.
16. How are you sleeping?
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0. I can sleep as well as usual.
1. I don’t sleep as well as I used to.
2. I wake up 1-2 hours earlier than usual and find it hard to get back to sleep.
3. I wake up several hours earlier than I used to and cannot get back to sleep.
17. Do you get more tired than usual?
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0. I don’t get more tired than usual.
1. I get tired more easily than I used to.
2. I get tired from doing almost anything.
3. I am too tired to do anything.
18. How is your appetite?
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0. My appetite is no worse than usual.
1. My appetite is not as good as it used to be.
2. My appetite is much worse now.
3. I have no appetite at all anymore.
19. Have you lost weight?
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0. I haven’t lost much weight, if any, lately.
1. I have lost more than five pounds.
2. I have lost more than ten pounds.
3. I have lost more than fifteen pounds.
20. Are you worried about your health?
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0. I am no more worried about my health than usual.
1. I am worried about physical problems like aches, pains, upset stomach, or constipation.
2. I am very worried about physical problems and it’s hard to think of much else.
3. I am so worried about my physical problems that I cannot think of anything else.
21. Have you lost interest in sex?
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0. I have not noticed any recent change in my interest in sex.
1. I am less interested in sex than I used to be.
2. I have almost no interest in sex.
3. I have lost interest in sex completely.
Name
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