You can print out this form if you wish and bring it to your first consultation.
1.In the last month has there been a period of time when you were feeling depressed or down most of the day nearly every day? If yes, did it last as long as 2 weeks?
2.What about being a lot less interested in most things or unable to enjoy the things you used to enjoy?
3.For the past couple of years, have you been bothered by a depressed mood most of the day, more days than not?
4.In the last six months, have you been particularly nervous or anxious?
5.Do you worry a lot about terrible things that might happen?
6.Have you ever had a panic attack, when you suddenly felt frightened, anxious or extremely uncomfortable?
7.Were you afraid of going out of the house alone, being in crowds, standing in line or traveling on buses or trains?
8.Is there anything that you were afraid to do or uncomfortable doing in front of other people like speaking, eating, or writing?
9. Have you had any unusual experiences, for example did it ever seem like people were ever talking about you or taking a special notice of you?
10.Was there ever a period of time when you drank too much? Has alcohol ever been a problem for you?
11.Has any one objected to your drinking?
12.Have you used any street drugs or have you used prescription drugs in an amount or way that wasn’t prescribed?
13.Have you ever had a time when you weighed much less than people thought you ought to weigh? At that time were you very afraid that you could become fat?
14.Have you ever had eating binges when you ate a lot in a short period of time? During these binges, did you feel your eating was out of control?