epartment of Education
D
Region V
Division of Camarines Sur
BONIFACIO D. BOREBOR SR. HIGH SCHOOL
(Formerly: Tawog National High School)
Tawog, Caramoan, Camarines Sur, 4429
Dear Respondents,
We are Grade 12 HUMSS-B of Bonifacio D. Borebor Sr. High School. We are working on research entitled
“ Perceived Depression Prevalence and Assessment of Senior High school Students”may we request you to
kindly answer the questionnaire. The information you provide will enable our group to attain the purpose of the study.
Rest assured that your data will be treated with utmost confidentiality. Thank you for your cooperation.
The Researchers.
SURVEY QUESTIONNAIRE
Name (Optional): ________________________ Age:_______________
Strand: ________________________________ Sex:_______________
Introductions: This questionnaire consist of 21 group of statements. Please read each group of statements
carefully, and then pick the one statement in each group that best describes the way you have been
feeling during the past two weeks, including today. Circle the number beside the statement you have
picked. If several statements in the groupseemtoapplyequallywell,circlethehighestnumberforthat
group.Besurethatyoudonotchoosemorethanonestatementofanygroup,includingitem16(changes
in sleeping pattern or item 18 (changes in appetite)
1. Sadness 6. Guilty Feelings
0 I do not feel sad. 0 I don’t feel particularly guilty.
1 I feel sad much of the time. 1 I feel guilty over many things I have done or should
2 I am sad all the time. have done.
3 I am so sad or unhappy that I can’t stand it. 2 I feel quite guilty most of the time.
3 I feel guilty all of the time.
2. Pessimism
0 I am not discouraged about my future. 7. Punishment Feelings
1 I feel more discouraged about my future than 0 I don’t feel I am being punished.
I used to be. 1 I feel I may be punished.
2 I do not expect things to work out for me. 2 I expect to be punished.
3 I feel my future is hopeless and will only get 3 I feel I am being punished.
worse.
8. Self-Dislike
3. P ast Failure 0 I feel the same about myself as ever.
0 I do not feel like a failure. 1 I have lost confidence in myself
1 I have failed more than I should have. 2 I am disappointed in myself
2 As I look back, I see a lot of failures. 3 I dislike myself.
3 I feel I am a total failure as a person.
9. Suicidal Thoughts or Wishes
4. L oss of Pleasure 0 I don’t have any thoughts of killing myself.
0 I get as much pleasure as I ever from the things I enjoy. 1 I have thoughts of killing myself, but I would not
1 I don’t enjoy things as much as I used to.
2 I get very little pleasure from the things I used to enjoy. carry them out
3 I can’t get any pleasure from the things I used to enjoy. 2 I would like to kill myself.
3 I would kill myself if I have the chance.
5. G uilty Feelings
0 I don’t feel particularly guilty. 10. C rying
1 I feel guilty over many things I have done or should have 0 I don’t cry anymore than I used to
done 1 I cry more than I used to.
2 I feel quite guilty most of the time. 2 I cry over every little things
3 I feel guilty all of thetime 3 I feel like crying, but I can’t.
11. Agitation
0 I am no more restless or wound up than usual. 17. Irritability
1 I feel more restless or wound up than usual. 0 I am so more irritable than usual.
1 I am so more irritable than usual
2 I am so restless or agitated that it’s hard to stay stiill. 2 I am much more irritable than usual
3 I am so restless or agitated that I have to keep moving or 3 I am irritable all the time
doing something.
18. Changes in appetite
12. L
oss of Interest 0 i have not experienced any changes in my appetite
0 I have not lost interest in other people or activities. —
1a. My appetite is somewhat less than usual.
1 I am less interested in other people or things than before. 1b My appetite is somewhat greater than usual.
2 I have lost most of my interest in other people or things. —
3 It’s hard to get interested in anything. 2a My appetite is much less than before.
2b My appetite is much greater than usual
13. I ndecisiveness —
0 I make decisions about as well as ever. 3a I have no appetite at all
3b I crave food all the time
1 I find it more difficult to make decisions than usual.
2 I have lost most of my interest in other people 19. C
oncentration difficulty
Or things 0 I can Concentrate as well as ever
3 It’s hard to get interested in anything. 1 I can’t concentrate as well as usual
2 It’s hard to keep my mind on anything very long.
3 I can’t concentrate on anything
14. W
orthlessness
0 I make decisions about as well as ever. 20. Tiredness or fatigue
1 I do not feel I am Worthless. 0 I am no more tired or fatigued than usual
2 I feel more worthless as compared to other people. 1 I get more tired or fatigued more easily than usual
3 I feel utterly worthless. 2 I am too tired or fatigued to do a lot of the things i used
to do
3 I am too tired or fatigued to do most of the things i
15. L
oss of energy used to do
0 I have as much energy as ever.
1 I have less energy than i used to have.
2 I don’t have enough energy to do anything.
3 I don’t have enough energy to do anything. Scoring the Beck Depression Inventory
fteryouhavecompletedthequestionnaire,addup
A
thescoreforeachofthe21questions.Thefollowing
16. C
hanges in sleeping pattern table indicatestherelationshipbetweentotalscore
0 I have not experienced any change in my sleeping and level of depression according to the Beck
pattern Depression Inventory
___
1a I sleep somewhat more than usual Classification Score Level of Depression
1b I sleep somewhat less than usual
— 1 -10 Normal ups and downs
Low
2a I sleep a lot more than usual
11 - 16 Mild mood disturbance
2b I sleep a lot less than usual
— 17 - 20 orderline clinical
B
3a I sleep most of the day Moderate depression
3b I wake up 1-2 hours early and can’t get back to sleep
21 - 30 Moderate Depression
31 - 40 Severe Depression
Significant
Over 40 Extreme Depression
