Columbia Depression Screen Health Questionnaire

Name*

First NameLast Name

Date*

Columbia DISC Depression Scale (Ages 11 and over)

Present State (last 4 weeks)

TO BE COMPLETED BY TEEN

Please answer the following questions as honestly as possible.

In the last four weeks ...*

	(0) No	(1) Yes
1. Have you often felt sad or depressed?
2. Have you felt like nothing is fun for you and you just aren't interested in anything?
3. Have you often felt grouchy or irritable and often in a bad mood, when even little things would make you mad?
4. Have you lost weight, more than just a few pounds?
5. Have you lost your appetite or often felt less like eating?
6. Have you gained a lot of weight, more than just a few pounds?
7. Have you felt much hungrier than usual or eaten a lot more than usual?
8. Have you had trouble sleeping, that is, trouble falling asleep, staying asleep, or waking up too early?
9. Have you slept more during the day than you usually do?
10. Have you often felt slowed down ... like you walked or talked much slower than you usually do?
11. Have you often felt restless ... like you just had to keep walking around?
12. Have you had less energy than you usually do?
13. Has doing even little things made you feel really tired?
14. Have you often blamed yourself for bad things that happened?
15. Have you felt you couldn't do anything well or that you weren't as good or as smart as other people?
16. Has it seemed like you couldn't think as clearly or as fast as usual?
17. Have you often had trouble keeping your mind on your [schoolwork/work] or other things?
18. Has it often been hard for you to make up your mind or to make decisions?
19. Have you often thought about death or about people who have died or about being dead yourself?
20. Have you thought seriously about killing yourself?
21. Have you tried to kill yourself in the last four weeks?
22. Have you EVER, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?