MOOD DISORDER QUESTIONNAIRE

Date: [Date completed]
Patient: [Name or record number, age]
Form: [Paper, tablet, or portal; language; read aloud or help given]
Reason for screening: [Depression before an antidepressant, poor response to treatment, intake, or other]

PART 1 TO PART 3
Part 1 yes count: [Number out of 13; any items left blank]
Part 2, same period: [Yes, no, or not answered]
Part 3, how much of a problem: [No, minor, moderate, or serious problem]
Family history and past diagnosis: [Answers to the two unscored questions, if on the form used]

SCREEN RESULT
Result: [Positive, negative, or incomplete until a blank part is answered]
Rule used: [Standard rule of 7 or more yes, same period, moderate or serious problem; or the modified rule your service uses]

HISTORY TAKEN TODAY
Periods described: [When, how long, sleep, energy, spending, risks taken, who noticed]
Current mood: [Depressed, elevated, mixed, or level, with PHQ-9 or other scores]
Other explanations: [Substances, stimulants or steroids, thyroid disease, ADHD, borderline personality, trauma]
Collateral: [Partner or family account with consent, or not yet obtained]
Impression: [Screen result in words, or working diagnosis]

DECISION
Next step: [Psychiatric assessment, referral, or watch and review]
Medication: [Antidepressant held or started, mood stabilizer, or no change, with the reason]
Safety: [Suicidal thoughts asked about directly, and the answer]
Follow-up: [Who arranges it and by when]

Screened by: [Name, credentials]