Anywhere School Health Center
DSM-IV ASSESSMENT
Patient Name:
Chart #:
_____
MAJOR DEPRESSIVE EPISODE
(5 or more)
1.
2.
3.
Depressed or irritable most of day, nearly every day
Diminished pleasure in activities
Decrease or increase in appetite associated with possible failure to make weight gain
4.
5.
6.
7.
8.
Insomnia or hypersomnia nearly every day
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or excessive inappropriate guilt
Suicidal ideation or attempt
Comments:
WV School Health Technical Assistance and Evaluation Center
Marshall University
1/18/2007
116102799
DSM-IV ASSESSMENT
Patient Name:
Chart #: ___________
DYSTHYMIA
(Depressed mood for most of the day, for more days than not, as indicated by subjective account
or observation by others)
(2 or more)
1. Depressed or irritable mood for most of the day x 1 year
2. Poor appetite or overeating
3. Insomnia or hypersomnia
4. Low energy or fatigue
5. Low self-esteem
6. Poor concentration or difficulty making decisions
7. Feelings of hopelessness
8. Never without symptoms for two (2) months, over a 1 year period
Comments:
Provider:
WV School Health Technical Assistance and Evaluation Center
Marshall University
Date:
1/18/2007
116102799
DSM-IV ASSESSMENT
Patient Name:
Chart #: ___________
ATTENTION-DEFICIT/HYPERACTIVITY DISORDER
(Some symptoms causing impairment were present before age 7. Some impairment from the
symptoms is present in 2 or more settings)
(6 or more)
Inattention
1. Often fails to give close attention to detail or careless mistakes
2. Often has difficulty sustaining attention in tasks or play
3. Often does not seem to listen when spoken to directly
4. Often avoids, dislikes or is reluctant to engage in tasks that require sustained attention
5. Often has difficulty organizing tasks and activities
6. Often does not follow through on instructions and fails to finish but not due to
oppositional behavior
7. Often is distracted by extraneous stimuli
8. Often is forgetful in daily activities
Comments:
Hyperactivity
1. Often fidgets with hands or feet or squirms in seat
2. Often leaves seat inappropriately
3. Often runs around and climbs inappropriately (in adolescents or adults (can be limited
feelings of restlessness)
4. Often cannot play quietly
5. Often on the go, driven by motor, etc.
6. Often talks excessively (impulsivity)
7. Often blurts out answers to questions before questions are complete
8. Often has difficulty waiting for turn
9. Often interrupts or intrudes on others
(6 or more)
Comments:
Provider:
WV School Health Technical Assistance and Evaluation Center
Marshall University
Date:
1/18/2007
116102799
DSM-IV ASSESSMENT
Patient Name:
Chart #: ___________
OPPOSITIONAL DEFIANT DISORDER
1. Often loses temper
Often argues with adults
2. Often actively defies or refuses to comply with adults’ requests or rules
3. Often deliberately annoys people
4. Often blames others for his or her mistakes or misbehavior
Is often touchy or easily annoyed by others
Is often angry and resentful
Is often spiteful or vindictive
(Four or more in last six months)
Comments:
Provider ________________________________ Date: ___________________
WV School Health Technical Assistance and Evaluation Center
Marshall University
1/18/2007
116102799
DSM-IV ASSESSMENT
Patient Name:
Chart #:
____
CONDUCT DISORDER
(Three or more in the past 12 months, with at least one in the past 6 months.)
1. Aggression to people and animals
 Often bullies, threatens, or intimidates others
 Often initiates physical fights
 Has used a weapon that can cause serious physical harm to others (e.g. bat, brick, broken
bottle, knife, gun)
 Has been physically cruel to people
 Has been physically cruel to animals
 Has stolen while confronting a victim (e.g. mugging, purse snatching, extortion, armed
robbery)
 Has forced someone into sexual activity
2. Destruction of property
 Has deliberately engaged in fire setting with the intention of causing serious damage
 Has deliberately destroyed others property (other than by fire setting)
3. Deceitfulness or theft
 Has broken into someone else’s house, building, or car
 Often lies to obtain goods or favors or to avoid obligations (i.e. “cons” others)
 Has stolen items of nontrivial value without confronting a victim (e.g. shoplifting, but
without breaking and entering; forgery)
4. Serious violations of rules
 Often stays out at night despite parental prohibitions, beginning before age 13
 Is often truant from school, beginning before age 13
WV School Health Technical Assistance and Evaluation Center
Marshall University
1/18/2007
116102799
Specify type based on age at onset
 Childhood - Onset Type: onset of at least one criteria characteristic of Conduct Disorder
prior to age 10
 Adolescent - Onset Type: absence of any criteria characteristic of Conduct Disorder prior
to age 10
Specify severity
 Mild: few if any conduct problems in excess of those required to make the diagnosis and
conduct problems cause only minor harm to others.
 Moderate: number of conduct porblems and effect on others intermediate between “mild”
and “severe”.
 Severe: many conduct problems in excess of those required to make the diagnosis or
conduct problems cause considerable harm to others.
Comments:
Provider:
WV School Health Technical Assistance and Evaluation Center
Marshall University
Date:
1/18/2007
116102799
DSM-IV ASSESSMENT
Patient Name:
Chart #:
300.02 GENERALIZED ANXIETY DISORDER
1. Excessive anxiety and worry for 6 months or longer
2. Patient unable to control anxiety
3. In children, one or more of the following:
a. Restlessness or feeling keyed up or on edge
b. Being easily fatigued
c. Difficulty concentrating or mind goes blank
d. Irritability
e. Muscle tension
f. Sleep disturbance (not usually early am awakenings)
Not just being worried about an Axis I diagnosis, not the result of ingesting a substance;
and must cause ….
WV School Health Technical Assistance and Evaluation Center
Marshall University
1/18/2007
116102799