Depression Symptom Checklist - Manhattan Marriage and ...€¦ · Dysthymic Mild Depression...

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Depression Symptom Checklist Dysthymic Mild Depression Moderate Depression Severe Depression Feelings Daily, Weekly, or Occasionally? Duration Sad, Hopeless, or Empty D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Dread, Gloom, Blah Moods D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Trouble Concentrating D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Irritable or Angry D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Defeat, Failure, Inadequacy D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Guilt D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Physical Symptoms Daily, Weekly, or Occasionally? Duration Backaches D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Headaches D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Heart Burn D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Low Sexual Desire D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Body Exhaustion D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Difficulty Sleeping D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Other: ___________________ D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Escapist Behaviors Daily, Weekly, or Occasionally? Duration Spending More Time at Work D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Excessive Sports or Other TV D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Affairs D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Alcohol or Drug Use D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Yelling, Name Calling, Put Down, Shaming D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Violent or Abusive Behavior D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Risky Behaviors, Excessive Risk Taking D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Loss of Interest in previously enjoyed activities D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Internalized Behaviors Daily, Weekly, or Occasionally? Duration Isolating from the Family D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Slow Response Times D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Withdrawing Emotionally or Physically D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Reluctant to share thoughts and feelings D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Work performance Issues D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ Negative Ruminating D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____ ©2018 Manhattan Marriage and Family Therapy, PLLC www.ManhattanMFT.com Bored Stressed

Transcript of Depression Symptom Checklist - Manhattan Marriage and ...€¦ · Dysthymic Mild Depression...

Page 1: Depression Symptom Checklist - Manhattan Marriage and ...€¦ · Dysthymic Mild Depression Moderate Depression Severe Depression Feelings Daily, Weekly, or Occasionally? Duration

Depression Symptom Checklist

Dysthymic Mild Depression Moderate Depression Severe Depression

Feelings Daily, Weekly, or Occasionally? Duration

Sad, Hopeless, or Empty D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Dread, Gloom, Blah Moods D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Trouble Concentrating D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Irritable or Angry D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Defeat, Failure, Inadequacy D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Guilt D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Physical Symptoms Daily, Weekly, or Occasionally? Duration

Backaches D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Headaches D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Heart Burn D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Low Sexual Desire D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Body Exhaustion D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Difficulty Sleeping D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Other: ___________________ D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Escapist Behaviors Daily, Weekly, or Occasionally? Duration

Spending More Time at Work D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Excessive Sports or Other TV D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Affairs D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Alcohol or Drug Use D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Yelling, Name Calling, Put Down, Shaming D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Violent or Abusive Behavior D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Risky Behaviors, Excessive Risk Taking D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Loss of Interest in previously enjoyed activities D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Internalized Behaviors Daily, Weekly, or Occasionally? Duration

Isolating from the Family D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Slow Response Times D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Withdrawing Emotionally or Physically D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Reluctant to share thoughts and feelings D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Work performance Issues D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

Negative Ruminating D_____ W_____ O______ 2 wks____ 3-6 mon_____ 1yr____ 2yrs_____

©2018 Manhattan Marriage and Family Therapy, PLLC www.ManhattanMFT.com

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