Columbia Depression Scale - Parent of Female Teen

Columbia Depression Scale - Parent of Female Teen

Present State (last 4 weeks) --- TO BE COMPLETED BY PARENT OF FEMALE TEEN
Patient name*

First NameLast Name
Patient date of birth*

MonthDayYear
Date
Who should form be sent to/who is your appointment with?*

Please answer as honestly as possible. In the last four weeks...

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

Total score
Should be Empty: