Smoking Cessation Assessment

Have you been formally diagnosed with depression?

Has a healthcare professional told you that you have social anxiety disorder?

Yes

What other, if any, psychiatric diagnoses do you have?

In the past three months, did you have eating binges or times when you ate a very large amount of food within a 2-hour period?

When was the last time you felt like yourself or felt happy, light, etc. ?

During these binges, did you feel that your eating was out of control?

On a scale of 0-10, with 10 being the most crippling depression you've ever felt, how depressed are you right now?

Do you experience fear or anxiety when performing in front of others, such as while speaking in front of a group of people?

Have you ever felt or do you currently feel suicidal?

Do you experience significant worrying in social situations with people you are not familiar with that is out of proportion to the threat posed?

If yes, when did you last feel suicidal?

Feel free to leave this section blank if you did not feel suicidal.

Are you currently taking medications for depression?

Do social situations almost always cause you to experience fear or anxiety?

Yes No Unsure

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