For more information, please visit your doctor.
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Understanding Depression

Depression Symptoms EmailPrint

 
If you feel you may be suffering from symptoms of depression, complete the following questionnaire and bring your responses in to your doctor. Discussing your responses may be helpful in determining what is bothering you and how to treat it.
 
Print and complete this questionnaire and bring it in to your doctor for every visit. Doing so will allow him to track your progress on your journey to improvement.

1. Please indicate which of the following symptoms you have been experiencing:

Feelings of sadness
Yes No


Noticeable loss of interest or pleasure in activities you used to enjoy
Yes No


Significant weight loss or gain
Yes No


Difficulty sleeping (waking up in the early morning rather than having
difficulty falling asleep), or sleeping too much
Yes No



Lack of interest or concern about what’s going on around you
Yes No


Feelings of restlessness
Yes No


No energy
Yes No


Feelings of worthlessness and/or guilt
Yes No


Difficulty concentrating or making decisions
Yes No


Unexplained aches or pains(such as headaches, stomach pain,
joint pains or other pains)
Yes No



2. Do your symptoms typically last most of the day?
Yes No
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3. Do you experience your symptoms nearly every day?
Yes No

4. Have you been experiencing your symptoms for at least 2 consecutive weeks?
Yes No

5. Have you found that your symptoms have interfered with or impaired your ability to take part in or carry out:

Social activities
Yes No


Family activities
Yes No


Work activities
Yes No


Other activities of day-to-day life
Yes No


  • Click here to print your answers


Adapted from the American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision. Washington, DC; American Psychiatric Association. 2000:345‐356.2



In addition to the questions you’ve already completed, fill in the below sections to provide your doctor with further information on your condition.

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A list of any medications you're taking. Include prescription drugs, over-the-counter medicines, herbal remedies, and nutritional supplements.

_________________________________________________________________________

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A list of any medical conditions you have. Note any chronic conditions (eg, diabetes, high blood pressure, or a recently diagnosed illness).

_________________________________________________________________________

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Any major life changes you've recently experienced. Don't forget positive events, too (e.g., getting married or receiving a promotion).

_________________________________________________________________________

_________________________________________________________________________

Your family medical history. Note any relatives who have suffered from depression or other mental illness, as well as any family history of suicide, alcoholism, substance abuse, or erratic behavior.

_________________________________________________________________________

_________________________________________________________________________

A list of treatments you've tried in the past, if any. Include alternative therapies, such as acupuncture or meditation.

_________________________________________________________________________

_________________________________________________________________________

 
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