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Modified Zung Depression Index
Jared Larsen
2020-09-22T17:18:11+00:00
Modified Zung Depression Index
Modified Zung Depression Index
Step
1
of
3
33%
Name
*
Name
First
Last
Please select your case manager
*
Please select your case manager
Choose one
Alma Orozco
Ashley Orozco
Bree Campbell
Brenda Rodriguez
Chase Dunakin
Chase Hebdon
Cindy Joyner
Elizabeth Miller
Hailey Moore
Jared Larsen
Jose Nava
Josh Esteron
Lucero Sanchez
Luis Cruz
Maria Martinez
Michele Mesaros
Monica Guerrero
Nathan Perdue
Veronica Barajas
Other
Instructions
Please indicate for each of these questions which answer best describes how you have been feeling.
I feel downhearted and sad
*
I feel downhearted and sad
Rarely or none of the time (less than 1 day per week)
Some or little of the time (1-2 days per week)
A moderate amount of time (3-4 days per week)
Most of the time (5-7 days per week)
Morning is when I feel best
*
Morning is when I feel best
Rarely or none of the time (less than 1 day per week)
Some or little of the time (1-2 days per week)
A moderate amount of time (3-4 days per week)
Most of the time (5-7 days per week)
I have crying spells or feel like it
*
I have crying spells or feel like it
Rarely or none of the time (less than 1 day per week)
Some or little of the time (1-2 days per week)
A moderate amount of time (3-4 days per week)
Most of the time (5-7 days per week)
I have trouble getting to sleep at night
*
I have trouble getting to sleep at night
Rarely or none of the time (less than 1 day per week)
Some or little of the time (1-2 days per week)
A moderate amount of time (3-4 days per week)
Most of the time (5-7 days per week)
I feel that nobody cares
*
I feel that nobody cares
Rarely or none of the time (less than 1 day per week)
Some or little of the time (1-2 days per week)
A moderate amount of time (3-4 days per week)
Most of the time (5-7 days per week)
I eat as much as I used to
*
I eat as much as I used to
Rarely or none of the time (less than 1 day per week)
Some or little of the time (1-2 days per week)
A moderate amount of time (3-4 days per week)
Most of the time (5-7 days per week)
I still enjoy sex
*
I still enjoy sex
Not Applicable
Rarely or none of the time (less than 1 day per week)
Some or little of the time (1-2 days per week)
A moderate amount of time (3-4 days per week)
Most of the time (5-7 days per week)
I notice I am losing weight
*
I notice I am losing weight
Rarely or none of the time (less than 1 day per week)
Some or little of the time (1-2 days per week)
A moderate amount of time (3-4 days per week)
Most of the time (5-7 days per week)
I have trouble with constipation
*
I have trouble with constipation
Rarely or none of the time (less than 1 day per week)
Some or little of the time (1-2 days per week)
A moderate amount of time (3-4 days per week)
Most of the time (5-7 days per week)
My heart beats faster than usual
*
My heart beats faster than usual
Rarely or none of the time (less than 1 day per week)
Some or little of the time (1-2 days per week)
A moderate amount of time (3-4 days per week)
Most of the time (5-7 days per week)
I get tired for no reason
*
I get tired for no reason
Rarely or none of the time (less than 1 day per week)
Some or little of the time (1-2 days per week)
A moderate amount of time (3-4 days per week)
Most of the time (5-7 days per week)
My mind is as clear as it used to be
*
My mind is as clear as it used to be
Rarely or none of the time (less than 1 day per week)
Some or little of the time (1-2 days per week)
A moderate amount of time (3-4 days per week)
Most of the time (5-7 days per week)
I tend to wake up too early
*
I tend to wake up too early
Rarely or none of the time (less than 1 day per week)
Some or little of the time (1-2 days per week)
A moderate amount of time (3-4 days per week)
Most of the time (5-7 days per week)
I find it easy to do the things I used to
*
I find it easy to do the things I used to
Rarely or none of the time (less than 1 day per week)
Some or little of the time (1-2 days per week)
A moderate amount of time (3-4 days per week)
Most of the time (5-7 days per week)
I am restless and can’t keep still
*
I am restless and can’t keep still
Rarely or none of the time (less than 1 day per week)
Some or little of the time (1-2 days per week)
A moderate amount of time (3-4 days per week)
Most of the time (5-7 days per week)
I feel hopeful about the future
*
I feel hopeful about the future
Rarely or none of the time (less than 1 day per week)
Some or little of the time (1-2 days per week)
A moderate amount of time (3-4 days per week)
Most of the time (5-7 days per week)
I am more irritable than usual
*
I am more irritable than usual
Rarely or none of the time (less than 1 day per week)
Some or little of the time (1-2 days per week)
A moderate amount of time (3-4 days per week)
Most of the time (5-7 days per week)
I find it easy to make a decision
*
I find it easy to make a decision
Rarely or none of the time (less than 1 day per week)
Some or little of the time (1-2 days per week)
A moderate amount of time (3-4 days per week)
Most of the time (5-7 days per week)
I feel quite guilty
*
I feel quite guilty
Rarely or none of the time (less than 1 day per week)
Some or little of the time (1-2 days per week)
A moderate amount of time (3-4 days per week)
Most of the time (5-7 days per week)
I feel that I am useful and needed
*
I feel that I am useful and needed
Rarely or none of the time (less than 1 day per week)
Some or little of the time (1-2 days per week)
A moderate amount of time (3-4 days per week)
Most of the time (5-7 days per week)
My life is pretty full
*
My life is pretty full
Rarely or none of the time (less than 1 day per week)
Some or little of the time (1-2 days per week)
A moderate amount of time (3-4 days per week)
Most of the time (5-7 days per week)
I feel that others would be better off I were dead
*
I feel that others would be better off I were dead
Rarely or none of the time (less than 1 day per week)
Some or little of the time (1-2 days per week)
A moderate amount of time (3-4 days per week)
Most of the time (5-7 days per week)
I am still able to enjoy the things I used to
*
I am still able to enjoy the things I used to
Rarely or none of the time (less than 1 day per week)
Some or little of the time (1-2 days per week)
A moderate amount of time (3-4 days per week)
Most of the time (5-7 days per week)
Medication
Please list all the medication you are taking for your injury
Please list the name of each medication. The frequency you are taking it. (e.g. 1x daily or 3x weekly etc.) and the duration. (How long have you been taking it.)
Medicine Name
Frequency
Duration
Δ
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Modified Zung Depression Index