Department of Education

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:_______________

Grade level & Strand:_______________________________________ Sex:_______________

Introductions: This questionnaire consist of 20 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 group seem to
apply equally well, circle the highest number for that group. Be sure that you do not choose more than one statement of
any group, including item 16 (changes in sleeping pattern or item 18 (changes in appetite)

1. Sadness
0 I do not feel sad. 8. Self-Criticalness
1 I feel sad much of the time. 0 I don’t criticize or blame myself more than usual
2 I am sad all the time. 1 I am more critical of myself than I used to be
3 I am so sad or unhappy that I can’t stand it.
2 I criticize myself for all of my faults
2. Pessimism 3 I blame myself for everything bad that happens
0 I am not discouraged about my future.
1 I feel more discouraged about my future than 9. Suicidal Thoughts or Wishes
I used to be. 0 I don’t have any thoughts of killing myself.
2 I do not expect things to work out for me.
3 I feel my future is hopeless and will only get 1 I have thoughts of killing myself, but I would not
worse. carry them out
2 I would like to kill myself.
3. Past Failure 3 I would kill myself if I have the chance.
0 I do not feel like a failure.
1 I have failed more than I should have. 10. Crying
2 As I look back, I see a lot of failures. 0 I don’t cry anymore than I used to
3 I feel I am a total failure as a person. 1 I cry more than I used to.
2 I cry over every little things
4. Loss of Pleasure 3 I feel like crying, but I can’t.
0 I get as much pleasure as I ever from the things I
enjoy. 11. Agitation
1 I don’t enjoy things as much as I used to.
2 I get very little pleasure from the things I used to 0 I am no more restless or wound up than usual.
enjoy. 1 I feel more restless or wound up than usual.
3 I can’t get any pleasure from the things I used to 2 I am so restless or agitated that it’s hard to stay
enjoy. stiill.
3 I am so restless or agitated that I have to keep
5. Guilty Feelings
0 I don’t feel particularly guilty. moving or doing something
1 I feel guilty over many things I have done or should
have done 12. Loss of Interest
2 I feel quite guilty most of the time. 0 I have not lost interest in other people or activities.
3 I feel guilty all of the time 1 I am less interested in other people or things than
6. Punishment Feelings before.
0 I don’t feel I am being punished. 2 I have lost most of my interest in other people or
1 I feel I may be punished. things.
2 I expect to be punished. 3 It’s hard to get interested in anything.
3 I feel I am being punished.

7. Self-Dislike 13. Indecisiveness

0 I feel the same about myself as ever. 0 I make decisions about as well as ever.
1 I have lost confidence in myself 1 I find it more difficult to make decisions than usual.
2 I am disappointed in myself 2 I have lost most of my interest in other people
3 I dislike myself. Or things
3 It’s hard to get interested in anything.
14. Worthlessness 17. Irritability
0 I make decisions about as well as ever. 0 I am so more irritable than usual.
1 I do not feel I am Worthless. 1 I am so more irritable than usual
2 I am much more irritable than usual
2 I feel more worthless as compared to other people. 3 I am irritable all the time
3 I feel utterly worthless.
18. Changes in appetite
15. Loss of energy 0 i have not experienced any changes in my appetite
0 I have as much energy as ever. —
1a. My appetite is somewhat less than usual.
1 I have less energy than i used to have. 1b My appetite is somewhat greater than usual.
2 I don’t have enough energy to do anything. —
3 I don’t have enough energy to do anything. 2a My appetite is much less than before.
2b My appetite is much greater than usual
16. Changes in sleeping pattern —
3a I have no appetite at all
0 I have not experienced any change in my sleeping 3b I crave food all the time
pattern
___ 19. Concentration difficulty
1a I sleep somewhat more than usual 0 I can Concentrate as well as ever
1b I sleep somewhat less than usual 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
2a I sleep a lot more than usual
2b I sleep a lot less than usual 20. Tiredness or fatigue
— 0 I am no more tired or fatigued than usual
3a I sleep most of the day 1 I get more tired or fatigued more easily than usual
2 I am too tired or fatigued to do a lot of the things i
3b I wake up 1-2 hours early and can’t get back to used to do
sleep 3 I am too tired or fatigued to do most of the things i
used to do

Scoring the Beck Depression Inventory

After you have completed the questionnaire, add up the score for each of the 21
questions. The following table indicates the relationship between total score and level of
depression according to the Beck Depression Inventory

Classification Score Level of Depression

1 -10 Normal ups and downs

Low
11 - 16 Mild mood disturbance

17 - 20 Borderline clinical
Moderate depression

21 - 30 Moderate Depression

31 - 40 Severe Depression
Significant
Over 40 Extreme Depression