These are questions may help you and your physician in diagnosing “Mood changes” , kindly discuss it with your physician if you need any further illustration .
For mobile users , its recommended to rotate the screen to get better view.
| Kindly select from the Yes/No drop list , if you have more comment kindly type it in the comments, |  | Comments | ||
| First Step : kindly answer the 2 Questions , if Yes go to the second step | ||||
| 1.During last month have you often been bothered by feeling down , depressed or hopeless? | Not at all | 0 | ||
| 2.Do you have little interest or pleasure in doing things? | Not at all | 0 | ||
| Second step: Kindly Answer theses Questions about Typical symptoms of Depression, select Yes if you have any symptom for 2 weeks or more , most of days & most of time | ||||
| 3.Feeling fatigue/ loss of energy. | Not at all | 0 | ||
| 4.Worthlessness/excessive or inappropriate guilt. | Not at all | 0 | ||
| 5.Recurrent thought of death , suicidal thoughts , or actual suicide attempts. | Not at all | 0 | ||
| 6.Diminished ability to think / concentrate or indecisiveness. | Not at all | 0 | ||
| 7.psycho-motor agitation or retardation (slow talk / movement or opposite : been fidget / restless). | Not at all | 0 | ||
| 8.Sleep disturbance (lack of sleep during night) / (increased sleep during day time). | Not at all | 0 | ||
| 9.Change in appetite (Loss / Over eating). | Not at all | 0 | ||
| 1-4 Minimal = minimal symptoms , no intervention needed 5-9 Mild = Watchful waiting: If symptoms persist in 2 wks / long subthreshold /previous severe depression , go to next level. 10-14 Moderate = Guided Self‐Help: Patients are provided with CBT, 3‐4 sessions , (medication If symptoms persisted in 2 wks )/ long subthreshold /previous severe depression. 15-19 Moderately severe = consider validated treatment (CBT,IPT) , Alternatively, consider Medication. , consider referral to psychiatry 20-27 Severe= Empirical medications in combination with validated treatment (CBT,IPT) , consider admission to psychiatry. | 0 | ↼Total | ||
| Kindly select how you consider these symptoms affecting your daily life and function | →→→→ | No difficult at all | ||
| Third step: symptoms of atypical depression | ||||
| Reactive mood (i.e., mood brightens in response to actual or potential positive events) | select | Emotional or social stressors, conversion ,somatization, sleep disorder. | ||
| Increased appetite / weight gain. | select | |||
| Feeling that your arms or legs are heavy. | select | |||
| Sleeping too much but still feeling sleepy in the daytime. | select | |||
| Sensitivity to rejection or criticism, which affects your relationships, social life or job. | select | |||
| Fourth Step : other questions | ||||
| Do you feel recurrent of depression annually at the same time each year with remission in between? | select | Seasonal | ||
| Do you have emotional / behavioral symptoms within 3 months of a specific stressor in your life? | select | Adjustment | ||
| Is there any link of your symptoms with other issues like (menstruation in female / Body shape) ? | select | Dysmorphic | ||
| Mania in Bipolar 1 (periods of over-active and excited behavior for 1 week) | ||||
| Do you feel a distinct period of abnormally and persistently elevated, expansive, or irritable mood / behavior or energy, lasting at least 1 week and present most of the day, nearly every day | select | |||
| Kindly select symptoms, if more than 1 , type in comments | ||||
| Hypomania in Bipolar 2 (Hypomania and mania are periods of over-active and excited behavior) | ||||
| Have you had at least one major depressive episode and at least one hypomanic episode, but you've never had a manic episode? | select | |||
| Cyclothymic disorder | ||||
| You've had at least two years — or one year in children and teenagers — of many periods of hypomania symptoms and periods of depressive symptoms (though less severe than major depression). | select | |||
| Medication / Alcohol / Medical Disease | ||||
| Do you Use certain drugs or alcohol or have medical condition, such as Cushing's disease, multiple sclerosis or stroke. | select | |||
| Grief / Bereavement | ||||
| Have you lost a (loved one / Relationship / Pet)? | select | |||
| Thank you for your completing this questionnaire , note these question are screening tool to help you along with your physician to consider certain psychological disorder , Nevertheless its not a confirmatory tool. |