CS_Dep. Tool: Depression Evaluation (Physician Tool)
| | | |
| | | |
|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 | |
| | |
| | |
|Additional Description of positive findings: |
| |
|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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