Mood Quiz

1

Choose the best answer for how you have felt over the past week

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2

Are you basically satisfied with your life? * This field is required

YesNo

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3

Have you dropped many of your activities and interests? * This field is required

YesNo

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4

Do you feel that your life is empty? * This field is required

YesNo

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5

Do you often get bored? * This field is required

YesNo

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6

Are you in good spirits most of the time? * This field is required

YesNo

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7

Are you afraid that something bad is going to happen to you? * This field is required

YesNo

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8

Do you feel happy most of the time? * This field is required

YesNo

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9

Do you often feel helpless? * This field is required

YesNo

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10

Do you prefer to stay at home, rather than going out and doing new things? * This field is required

YesNo

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11

Do you feel you have more problems with memory than most? * This field is required

YesNo

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12

Do you think it is wonderful to be alive now? * This field is required

YesNo

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13

Do you feel worthless the way you are now? * This field is required

YesNo

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14

Do you feel full of energy? * This field is required

YesNo

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15

Do you feel that your situation is hopeless? * This field is required

YesNo

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16

Do you think that most people are better off than you are? * This field is required

YesNo

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17

ScoreIf your score is 6 or more, it may mean that you have depression - you should tell your doctor.

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18

Email* This field is requiredWe will send a copy of your quiz to the email address provided below

example@example.com

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19

Name* This field is requiredBy typing your name and submitting your data, you acknowledge agreement to the Terms and Conditions found on the Modiin Neurology Clinic website (www.modiinneurology.com)

First Name

Last Name

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