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Short Survey
This short survey will only take a minute to complete and will help us monitor how you are doing. If you are a caregiver, please answer the questions as they relate to the Fidelis Care member identified below.
Name
First
Last
Please check the answer that comes closest to how you have felt IN THE PAST 2 WEEKS, not just how you feel today. Over the past 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things
*
Not at all
Several Days
More than half the days
Nearly every day
Feeling down, depressed or hopeless
*
Not at all
Several Days
More than half the days
Nearly every day
Trouble falling asleep, staying asleep, or sleeping too much
*
Not at all
Several Days
More than half the days
Nearly every day
Feeling tired or having little energy
*
Not at all
Several Days
More than half the days
Nearly every day
Poor appetite or overeating
*
Not at all
Several Days
More than half the days
Nearly every day
Feeling bad about yourself - or that you’re a failure or have let yourself or your family down
*
Not at all
Several Days
More than half the days
Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television
*
Not at all
Several Days
More than half the days
Nearly every day
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
*
Not at all
Several Days
More than half the days
Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way
*
Not at all
Several Days
More than half the days
Nearly every day
Hidden
Score
Hidden
region
Hidden
mobile
Hidden
county
Hidden
status
Hidden
EscalationEmail
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