Periodic Survey | Brand New Day

This short survey will only take a few minutes to complete and will help us monitor how you are doing.

In general, would you say your health is:?*

The following questions are about activities you might do during a typical day. Does your health now limit your ability to do the following activities?

Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf*

Yes, limited a lot
Yes, limited a little
No, not limited at all

Climbing several flights of stairs*

Yes, limited a lot
Yes, limited a little
No, not limited at all

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

Accomplished less than you would like as a result of your physical health?*

No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time

Were limited in the kind of work or other activities as result of your physical health?*

No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time

During the past 4 weeks, how much did pain interfere with your regular daily activities?*

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of emotional problems (such as feeling depressed or anxious)?

Accomplished less than you would like as a result of emotional problems*

No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time

Didn't do work or other activities as carefully as usual as a result of emotional problems*

No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time

Over the past 2 weeks, how often have you been bothered by any of the following?

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

Hidden

PHQ-2 Score

We'd just like to ask a few more questions

Over the past 2 weeks, how often have you had trouble falling asleep, staying asleep, or sleeping too much?*

Not at all
Several days
More than half the days
Nearly every day

Over the past 2 weeks, how often have you felt tired or had little energy?*

Not at all
Several days
More than half the days
Nearly every day

Over the past 2 weeks, how often have you had a poor appetite or overeaten?*

Not at all
Several days
More than half the days
Nearly every day

Over the past 2 weeks, how often have you felt 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

Over the past 2 weeks, how often have you had 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

Over the past 2 weeks, how often have moved or spoken so slowly that other people could have noticed? Or, the opposite – been so fidgety or restless that you have been moving a lot more than usual?*

Not at all
Several days
More than half the days
Nearly every day

Over the past 2 weeks, how often have you had 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

PHQ2 + PHQ9 Score