Alexandre Mitellus

Burn Depression Checklist

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Burn's Depression Checklist

Please answer all questions based on how you have been feeling over the past 30 days. Select one option per question. All answers are required.

Please enter your name. Please enter a valid email address.
GDPR consent is required.
Mental health consent is required.

Thoughts and Feelings

1. Feeling sad or down in the dumps

2. Feeling unhappy or blue

3. Crying spells or tearfulness

4. Feeling discouraged

5. Feeling hopeless

6. Low Self-Esteem

7. Feeling worthless or inadequate

8. Guilt or shame

9. Criticising yourself or blaming others

10. Difficulty in making decisions

Activities and Personal Relationships

11. Loss of interest in family, friends or colleagues

12. Loneliness

13. Spending less time with family or friends

14. Loss of motivation

15. Loss of interest in work or other activities

16. Avoiding work or other activities

17. Loss of pleasure or satisfaction in life

Physical Symptoms

18. Feeling tired

19. Difficulty sleeping or sleeping too much

20. Decrease or increases appetite

21. Loss of interest in sex

22. Worrying about your health

Suicidal Urges

23. Do you have any suicidal thoughts?

24. Would you like to end your life?

25. Do you have a plan for harming yourself?

Please answer all questions.

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