Diagnosis Form

Name *

First Name

Last Name

Depression Assessment *

Please check the boxes for any symptoms that have come up in moderate to severe occurrence within 2 week period (5).

Depressed moodMost of the day, nearly every day; may be subjective (e.g. feels sad, empty, hopeless) or observed by others (e.g. appears tearful); in children and adolescents, can be irritable mood

Loss of interest/pleasureMarkedly diminished interest/pleasure in all (or almost all) activities most of the day, nearly every day; may be subjective or observed by othersWeight loss or gain

Significant weight loss (without dieting) or gain (change of >5% body weight in a month), or decrease or increase in appetite nearly every day; in children, may be failure to gain weight as expected

Insomnia or hypersomnia, nearly every day

Psychomotor agitation or retardationNearly every day and observable by others (not merely subjectively restless or slow)

FatigueOr loss of energy, nearly every day

Feeling worthless or excessive/inappropriate guilt nearly every day; guilt may be delusional; not merely self reproach or guilt about being sick

Decreased concentration nearly every day; may be indecisiveness; may be subjective or observed by othersThoughts of death/suicide

Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without specific plan, or suicide attempt, or a specific plan for suicide

Additional Criteria *

Please check the boxes for any symptoms that have come up in moderate to severe occurrence within 2 week period (4/ rule out).

Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

Episode not attributable to physiological effects of a substance or another medical condition

Episode not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disordersNo history of manic or hypomanic episode

Exclusion does not apply if all manic-like or hypomanic-like episodes are substance-induced or are attributable to physiological effects of another medical condition