My name is …

My (10 digit) mobile number is …

 Please call me back on this number.

I have a low mood since …---1 week2 to 3 weeksMonthMore than few months

I have low mood …---Without any specific reasonDue to a family problemDue to my professional problemsDue to my interpersonal problems with my spouseDue to another specific reason

Because of my low mood …---I am unable to workI am unable to sleepMy appetite has decreasedMy sexual desire (libido) has decreasedAll of the above

When I feel sad …---I feel like cryingI feel like dying i.e. committing suicideAll of the aboveNone of the above

Because of depression …---I avoid my friendsI avoid all pleasurable activities and my hobbiesI avoid social functionsAll of the aboveNone of the above

I feel …---Hopeless about futureHelpless to solve my problemsUnable to help or contribute to wellbeing of othersWorthless about myselfAll of the aboveNone of the above

I feel …---Less energetic rarelyLess energetic most of the timesLess energetic always

I have multiple physical complaints …---OccasionallyMost of the timesAlways

Due to depression my work …---Has not been affected at allAffected to some extentAffected to large extentHas stopped

People around me …---Find me to be irritableFeel I am not interested in anythingTry to trouble meAll of the aboveNone of the above