Mood and Anxiety Disorders Program

Mood and Anxiety Disorders Program

Depression Questionnaire

Today’s Date: ______

Name:______

Address:______

City/State/Zip:______

Day Phone#:______Home Phone#:______Cell Phone: #______

OKto leave messages?_____OK to leave messages? ______OK to leave messages? ______

Email Address? ______

How did you learn about the study? ______

______

Date of Birth: ______Age: _____

Sex: Male:_____ Female:_____

۰ MARITAL STATUS۰ RACIAL BACKGROUND

Never married / living aloneAfrican American / African /Haitian

Never married / living with partner ____ (how long)Asian: Far East/Near East / India/Philippines

Married _____(how long) _____ (number of times)Caucasian: European/Middle East /N.Africa

Separated _____(how long)Native American / Alaska / Central America

DivorcedPacific Islander: Hawaii / Samoa

WidowedMultiple / More than one race

Other______

HispanicYes No

In the past 2 weeks. . . .

Have you felt significantly down, sad or depressed?

Yes No

Have you felt a loss of interest or pleasure in all, or almost all activities?

Yes No

Have you had a decreased or increased appetite? Have you lost or gained weight? Yes No
Have you felt like your energy was low, or you were slowed down?

Yes No

Have you had difficulty sleeping or sleeping too much?

Yes No

Have you had difficulty concentrating or making decisions?

Yes No

Have you felt worthless or guilty about things you’ve done or not done?

Yes No

Are you currently receiving treatment for depression? Yes No

If Yes:Medication______Therapy ______

Have you ever received medication or therapy for depression or anxiety?Yes No

Have you ever taken escitalopram (Lexapro)? Yes No

Have you ever taken duloxetine (Cymbalta)? Yes No

Have you ever received any psychotherapy/talk therapy or counseling?Yes No

If yes, please indicate type of psychotherapy

____Cognitive Behavioral Therapy (CBT)

____Interpersonal Therapy (IPT)

____Marital/Couples Therapy

____Other____Not sure.

Are you now or have you ever been treated for any other psychiatric disorder?

____Psychotic Depression ____Bipolar Disorder

____Schizophrenia ____ Obsessive Compulsive Disorder

____None ____Other (please describe) ______

How many alcohol beverages do you drink per week, on average? ______/week

Do you have a history of any of the following medical conditions?____None

Heart problems______Bleeding disorder_____

Thyroid Problems_____Head Injury______

Cancer______Hepatitis ______

Seizures______Blood Pressure problems_____

Diabetes ______Other______(please describe)

______

Do you have any metal objects (clips, pins, braces etc.) in your body? Yes ____ No ____

Are you currently taking any prescribed medications other than those for depression or anxiety?

Yes _____No _____

If yes, what medications are you currently taking?

______

FOR WOMEN ONLY (noted by *)

*If a female of child bearing potential, are you pregnant or nursing or have you been pregnant within the past year? Yes _____ No _____

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OFFICE USE ONLY

SCHEDULING:

Appt Date ______Appointment Time______Scheduled by: ______

OK to email or mail intake packet? Yes _____No _____

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