CS_Dep. Tool: Depression Evaluation (Physician Tool)



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|Date: | | |Name | |

|Age: | |Story of the Illness |ROS |

| | | |circle positives |

| | | |Nerves |

| | | |Headache |

| | | |Pain |

| | | |Sex |

| | | |Tired |

| | | |Health |

| | | |Sleep |

| | | |Weight |

| | | |Memory |

| | | |Digestive |

| | | |Constipation |

| | | |Bereaved |

| | | |Move |

| | | |Abuse |

| | | |Job loss |

| | | |Pet |

| | | |

|PHQ-9 | | |

|Anhedonia _ _ | | |

|Dysphoria _ _ | | |

|Insomnia _ _ | | |

|Tired _ _ | | |

|Appetite _ _ | | |

|Failure _ _ | | |

|Concentration _ _ | | |

|Slow/restless _ _ | | |

|Death _ _ | | |

|Score _ _ | | |

|Difficulty _ _ | | |

| | | |

| | | |

| | | |

| | | |

| |Current Medical History | |

| | | |

| | | |

| | | |

|Past Med Hx | | |

|check positives | | |

|CAD ο | | |

|Thyroid ο | | |

|CVA ο | | |

|Parkinson’s ο | | |

|Alcoholism ο | | |

|Depression ο | | |

|Suicide ο | | |

|Drug ο | | |

|Cancer ο | | |

|Sensory ο | | |

|Pain ο | | |

|Dementia ο | | |

|Anxiety ο | | |

|Psych ο | | |

|Manic ο | | |

|Diabetes ο | | |

| |Psychiatric History | |

| | | |

| | |Education |

| | |/yrs. |

| | |Employment |

| |Medications | |

| | |CAGE Questionnaire |

| | | |

| | |circle positives |

| | |Cut down |

| | |Annoyed |

| | |Guilt |

| | |Eye opener |

| | |Health Habits: |

| | |Tobacco |

| | |/pk-yrs. |

| | | |

| | |Alcohol |

| | |/day |

| | | |

| |Positives (FHx, occup., habits, function) | |

| | | |

|Fam Hx | | |

|Dementia ο | | |

|Parkinson’s ο | | |

|Depression ο | | |

|Stroke ο | | |

|CAD ο | | |

|Diabetes ο | | |

|Mental illness ο | | |

|Suicide ο | | |

| |

|Vital Signs BP P T Wt. lb Ht. in |

|Eyes ο nl conjunctiva & lids |MS Gait ο nl gait & station |

|Pupils ο pupils symmetrical, reactive |Nails ο no clubbing, cyanosis |

|Fundus ο nl discs & pos elements |Check nl, circ abn ROM Strength Tone Abnormals |

|ENT-External ο no scars, lesions, masses | ο ο ο ο |

|Otoscopic ο nl canals & tympanic membranes | |

|Hearing ο nl to _ ________ | |

|Intranasal ο nl mucosa, septum, turbinate | |

|Ant. Oral ο nl lips, teeth, gums | |

|Oropharynx ο nl tongue, palate, pharynx | |

| |Skin ο nl to inspection & palpation |

| |Neurologic ο nl alertness, attentive |

| |Cranial nerves ο w/o gross deficit |

| |Coordination ο nl rapid alternating movement |

|Neck palp. ο symmetrical without masses |DTR’s ο symmetrical, __ (scale: 0-4+) |

|Thyroid ο no enlargement or tenderness |Sensation ο nl touch, proprioception |

|Resp. effort ο nl without retractions | |MMSE |

|Chest percuss. ο no dullness or hyperresonance | | |

|Chest palp. ο no fremitus | | |

|Auscultation ο nl bilateral breath sounds w/o rales | | |

| |Psych Orient’n ο nl to day, mo, yr, time, location _ /10 |

| |Registration ο register 3 items _ _/3 |

| |Attn/Calc ο serial subtraction, world bckwd _ _/5 |

|Heart palp. ο nl location, size |Recall ο recall 3 items _ _/3 |

|Cardiac ausc. ο no murmur, gallop, or rub |Language ο nl nam’g, repit’n,compr’n, read’g, rit’g _ _/8 |

|Carotids ο nl intensity w/o bruit |Visuospatial ο copy design, clock _ _/1 |

|Pedal pulses ο nl posterior tibial & dorsalis pedis |Knowledge ο current/past presidents totals _ /30 |

| |Mood ο nl GDS GDS Score _ _/15 |

|Breasts ο nl inspection & palpation |GDS (circle positives) |

| |Satisfied Afraid Wonderful |

| |Dropped Happy Worthless |

| |Empty Helpless Energy |

| |Bored Stay home Hopeless |

| |Spirits Memory Others better |

|Abdomen ο no masses or tenderness | |

|L/S ο no liver/spleen | |

|Hernia ο no hernia identified | |

|Anus/rectal ο no abnormality or masses | |

|GU male ο nl to inspection & palpation | |

|Prostate ο nl size w/o nodularity | |

|GU female ο external genitalia nl w/o lesions | |

|Int. inspection ο nl bladder, urethra, & vagina | |

|Cervix ο nl appearance w/o discharge | |

|Uterus ο nl size, position, w/o tenderness | |

|Adnexa ο no masses or tenderness | |

| |Better off dead? |

| |Considered harming yourself? |

| |Speech ο nl rate, volume |

| |Thought cont. ο logical, coherent |

| |Psychosis ο no hallucinations, delusions |

| |Judgement ο nl |

| |Behavior ο cooperative, appropriate |

|Lymphatic ο nl neck & axillae | |

|Lymph other ο | |

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|Additional Description of positive findings: |

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|Diagnostic Assessment |

|Recommendations |

| | |Educational Materials |

| | |Depression |

| | |How Do I Know If I’m Depressed? |

| | |Evaluation of Depression |

| | |Treatment of Depression |

| | |Drug Treatment of Depression |

| | |Mental Health Specialists |

| | |Taking Care of Yourself |

| | |What If I Don’t Feel Better? |

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