Depression Screen - Bright Futures - Cottonwood Pediatrics

Please have your child fill out the depression screen below based on LAST WEEK.

Child's Full Name*
Child's Date of Birth*
MM slash DD slash YYYY
1. I was bothered by things that usually don't bother me.*
2. I did not feel like eating, I wasn’t very hungry*
3. I wasn’t able to feel happy, even when my family or friends tried to help me feel better*
4. I felt like I was just as good as other kids.*
5. I felt like I couldn’t pay attention to what I was doing.*
6. I felt down and unhappy.*
7. I felt like I was too tired to do things.*
8. I felt like something good was going to happen.*
9. I felt like things I did before didn’t work out right.*
10. I felt scared.*
11. I didn’t sleep as well as I usually sleep.*
12. I was happy.*
13. I was more quiet than usual.*
14. I felt lonely, like I didn’t have any friends.*
15. I felt like kids I know were not friendly or that they didn’t want to be with me.*
16. I had a good time.*
17. I felt like crying.*
18. I felt sad.*
19. I felt people didn’t like me.*
20. It was hard to get started doing things.*

www.brightfutures.org

Always review mental health benefits with your insurance.

Depression Screen – Bright Futures