Depression

Depression Questionnaire
Please answer all questions applicable to the client's medical history.
Questions? Call Jim or Teresa at 877.564.1707.
Producer Name*
Phone*
Email*
Date
MM slash DD slash YYYY
Client Name
Date of Birth
MM slash DD slash YYYY
Gender
- Male
- Female
Face Amount
Max Premium $/year
Type
Has the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?
- Yes
- No
Frequency
Date of Last Use
Type
Date(s) of initial and subsequent episodes of depression:
What specific type(s) of depression has been diagnosed?
- Bipolar disorder (mixed)
- Bipolar disorder (manic)
- Bipolar disorder (depressed)
- Dysthymia
- Major depression
- Anxiety
- Situational depression
- Other
If other, please describe:
What medications are used to treat the condition?
Click the + sign to add additional medications.
Type Usual Quantity Frequency of Use How Taken Dates: From-To
Has the client ever been hospitalized or gone to the Emergency Room for any depression/anxiety symptoms?
- Yes
- No
If yes, list date(s):
Has the client been treated with electric shock therapy (ECT)?
- Yes
- No
If yes, total number of ECT treatments:
Date of first ECT treatment:
MM slash DD slash YYYY
Date of most recent ECT treatment:
MM slash DD slash YYYY
Has the client had (or been diagnosed with) Alcohol/Drug abuse?
- Yes
- No
Date of last use:
MM slash DD slash YYYY
Has the client had (or been diagnosed with) Anorexia/Bulimia nervosa?
- Yes
- No
Date diagnosed:
MM slash DD slash YYYY
Has the client had (or been diagnosed with) Personality/Psychotic disorder?
- Yes
- No
Date diagnosed and exact name of condition:
MM slash DD slash YYYY
Has the client had (or been diagnosed with) suicidal thoughts/attempts?
- Yes
- No
Date of last such thought/attempt:
MM slash DD slash YYYY
The client is:
- Working
- On disability
List any other major health problems the client has:
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Type	Usual Quantity	Frequency of Use	How Taken	Dates: From-To

Depression

Depression Questionnaire