DEMOGRAPHIC INVENTORY

1. Race/Ethnicity
2. Current marital status (Check one):
3. If you are married or cohabitating with partner, how long has this been?
4. Number of previous marriages?
5. How many children do you have?
6. TOTAL number of persons including yourself in your household?
7. How many years of formal education have you completed?
8. Highest degree obtained: (Check only one)
9. What best describes your current employment status? (Check one from each category a, b, & c)
a. Employment Status
b. Student Status
c. Volunteer Status
10. Type of occupation? (Check only one)
Spousal Information
12. Highest degree your spouse has obtained: (Check only one)
13. What best describes your spouse’s current employment status? (Check one from each a, b, & c)
a. Employment Status
b. Student Status
c. Volunteer Status
14. Spouse’s type of occupation? (Check only one)
Household: income
Current residence:
What is the major mode of
transportation that you use?
(check one)

MEDICAL & MENTAL HEALTH HISTORY

Have you ever had any of the following (check all that apply):
Please list current or past medications you have taken for the treatment of any medical problem.
Medical Problem Medication (name/dose) Start Date Stop Date Currently Taking?
Medical Problem
Medication (name/dose)
Start Date
Stop Date
Currently Taking?
What kind of birth control are you using?
How much alcohol, including beer, do you drink per week?
Mental Health History Have you ever had a problem with any of the following (check all that apply):
Please list current or past medications you have taken for the treatment of any mental health problem.
Problem (e.g. Depression, Anxiety) Medication (name and highest dose) Start Date Stop Date Why stopped (e.g. felt better, didn’t help)
Has anyone in your family ever been treated for any of the following (check all that apply):
Are you currently seeing a counselor or therapist?
Are you having problems concentrating or problems remembering things?
Additional Medications

Please list any medications you are taking that have not been listed above, including birth control pills, any over the counter medications and herbal remedies (i.e. decongestants, St. John's Wart, vitamins).

Medication (name/dose) Start Date Stop Date Physician
Medication Allergies
Medication (name/dose) Type of Reaction
Physical Activity
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were doing physical activity?
Do you lose you balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?
Is you doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
How much do you exercise each week?
UTSW Antidepressant Treatment History Evaluation Have you taken any of the anti-depressant medications listed below?

If yes, please indicated: 1) What dosage did you take? 2) How many weeks did you take the medication? 3) Did it result in 50% reduction of depressive symptoms? 4) Did you have any troubling side effects that made it difficult to take the medication?

Diagnostic Screening Questionnaire (DSQ)

QUICK INVENTORY OF DEPRESSIVE SYMPTOMATOLOGY (SELF-REPORT) (QIDS-SR16)

National Network of Depression Centers

Common Assessment Package: Self-Rated

Patient Health Questionnaire (PHQ-9)

Instructions: Please choose one number for each statement.

PHQ-9 Copyright © 1999 Pfizer Inc. All rights reserved.

NNDC Common Assessment Package: Self-Rated (January 25, 2011)

National Network of Depression Centers

Common Assessment Package: Self-Rated

Generalized Anxiety Disorder Scale (GAD-7)

Instructions: Please choose one number for each statement.

Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006;166:1092-97.

NNDC Common Assessment Package: Self-Rated (January 25, 2011)

National Network of Depression Centers

Common Assessment Package: Self-Rated

Altman Self-Rating Mania Scale (ASRM)

Instructions:

  • On this questionnaire are groups of 5 statements; read each group of statements carefully.
  • Choose the one statement in each group that best describes the way you have been feeling for the past week.
  • Please note:The word “occasionally” when used here means once or twice; “often” means several times or more; “frequently” means most of the time.

NNDC Common Assessment Package: Self-Rated (January 25, 2011)

National Network of Depression Centers

Common Assessment Package: Self-Rated (Baseline)

Work and Social Adjustment Scale (WSAS)

Instructions: Rate each of the following questions on a 0 to 8 scale: 0 indicates no impairment at all and 8 indicates very severe impairment. Please choose your responses below.

Mundt, J.C., Marks, I.M., Shear, M.K., & Greist, J.H. (2002). The Work and Social Adjustment Scale: a simple measure of impairment in functioning. Br J Psychiatry, 180, 461-464.

NNDC Common Assessment Package, Baseline: Self-Rated (Fabruary 14, 2011)