DSM-V Pathological Gambling Diagnostic Form

Choices Mental Health Counseling PLLC

Narrowsburg, NY 12764
DSM-V Pathological Gambling Diagnostic Form
Name*

First NameLast Name
Today’s Date*

MonthDayYear
Date
Persistent and recurrent maladaptive gambling behavior as indicated by Four (or more) of the following criteria):

IN THE PAST YEAR

	Yes	No
1. Have you often found yourself reliving past gambling (e.g. reliving past experiences, planning the next time you will play or thinking of ways to get more money to gamble)?
2. Have you needed to gamble with more and more money to get the amount of excitement you are looking for?
3. Have you become restless or irritable when trying to cut down or stop gambling?
4. Have you gambled to escape from problems or when you are feeling depressed, anxious, or bad about yourself?
5. After losing money gambling, have you returned another day in order to get even?
6. Have you lied to your family or others to hide the extent of your gambling?
7. Have you made repeated unsuccessful attempts to control, cut back or stop gambling?
8. Have you risked or lost a significant relationship, job, educational or career opportunity because of gambling?
9. Have you sought help from others to provide the money to relieve a desperate financial situation caused by gambling?

Score
**4 or more “yes” answers indicates a diagnosis for Gambling Disorder – please see DSM-V for further diagnostic criteria.

**Less than 4 indicates a potential problem and/or at risk indicators which may warrant further support, education and treatment services.

Adapted from the American Psychiatric Association Diagnostic Criteria from the DSM V 2013
Should be Empty: