Columbia Depression Scale - Parent of Male Teen
Present State (last 4 weeks) --- TO BE COMPLETED BY PARENT OF MALE TEEN
Patient name
*
First Name
Last Name
Patient date of birth
*
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Month
-
Day
Year
Date
Who should form be sent to/who is your appointment with?
*
Agganis, Georgia
Aldrich, Meghan
Amin, Priyal
Athanasiou, Andreas
Balestrieri, Karen
Coleman, Russell
Daly, James
Eagan, Joan
Foley, Megan
Goharfar, Behzad
Grossman, Emily
Hall, Alexandra
Hiltunen, Karen
Hohmann, Deanna
Jackson, Patricia
Jensen, Susan
Jones, Eliza
Kelleher, Susan
Laurin Kinney, Jayne
Leonhardt, Julie Bonner
Narayan, Sara
Oliver, Dana
Scott, Kendra
Sheehy, James
Stimpson, Devin
Suriani, Christine
Triehy-Kreitler, Ashley
Voute, Susan
Wilson, Kathryn
*** Other ***
Please answer as honestly as possible. In the last four weeks...
No
Yes
1. Has he often seemed sad or depressed?
2. Has it seemed like nothing was fun for him and he just wasn’t interested in anything?
3. Has he often been grouchy or irritable and often in a bad mood, when even little things would make him mad?
4. Has he lost weight, more than just a few pounds?
5. Has it seemed like he lost his appetite or ate a lot less than usual?
6. Has he gained a lot of weight, more than just a few pounds?
7. Has it seemed like he felt much hungrier than usual or ate a lot more than usual?
8. Has he had trouble sleeping – that is, trouble falling asleep, staying asleep, or waking up too early?
9. Has he slept more during the day than he usually does?
10. Has he seemed to do things like walking or talking much more slowly than usual?
11. Has he often seemed restless … like he just had to keep walking around?
12. Has he seemed to have less energy than he usually does?
13. Has doing even little things seemed to make him feel really tired?
14. Has he often blamed himself for bad things that happened?
15. Has he said he couldn’t do anything well or that he wasn’t as good looking or as smart as other people?
16. Has it seemed like he couldn’t think as clearly or as fast as usual?
17. Has he often seemed to have trouble keeping his mind on his [schoolwork/work] or other things?
18. Has it often seemed hard for him to make up his mind or to make decisions?
19. Has he said he often thought about death or about people who had died or about being dead himself?
20. Has he talked seriously about killing himself?
21. Has he EVER, in his WHOLE LIFE, tried to kill himself or made a suicide attempt?
22. Has he tried to kill himself in the last four weeks?
Total score
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