Depression Risk Assessment

1. In the last year have you thought seriously about killing yourself? Yes No

2. Have any of these stressful events happened to you during the last 12 months? (Check all that apply.) Loss of a spouse, family member, or loved one Divorce Loss of a job A serious illness or surgery A serious financial downfall None

3. Have you been in trouble with the law in the last 12 months? Yes No

4. Has someone close to you recently committed suicide? Yes No

5. Has anyone in your family (parents, grandparents, great-grandparents, brothers, sisters, aunts, or uncles) had any of the following conditions? (Check all that apply.) Alcoholism in any first-degree family member(s) (mother, father, brother, sister) Bipolar disorder Depression Suicide (attempted or committed) None

6. Do you have or have you ever had any of these conditions? (Check all that apply.) Heart attack (myocardial infarction). Alcoholism Type 2 diabetes Type 1 diabetes Kidney disease HIV positive or HIV infection Anorexia nervosa Bulimia binge/purge Hepatitis C Multiple sclerosis Suicide attempt Bipolar disorder Depression Cancer None

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