Depression Checklist Please enable JavaScript in your browser to complete this form.Name *FirstLastEyes, Ears, NoseDouble VisionDifficulty focusing visionEye PainIncrease/Decrease in tearingEar PainMuffled/plugged hearingSinus Pain/PressureNosebleedsCongestionCardiovascularChest PainChest DiscomfortHeart poundingRespiratoryCoughWheezingShortness of BreathPain with breathingGastrointestinalDiarrheaConstipationHeartburnRectal BleedingBlack/tarry stoolsStomach PainFood IntoleranceAbdominal bloatingUrinaryFrequent UrinationPainful UrinationDifficulty urinatingBlood in urineGeneral SymptomsAgitatedChillsConstant WorryDecrease in sex driveDizziness or light headednessEasy bruisingExcessive feelings of guiltFainting or feeling faintFatigue or lack of energyFear of doing something uncontrollableFear of dyingFear of going crazyFear of losing controlFearful feelingsFeeling in a dream-like stateFeeling life is not worth living FeverFrequent crying or weepingFrequent negative thinkingFrequent thoughts of death or suicide HeadacheHelpless feelingsHopeless feelingsIncrease or decrease in appetiteIncrease or decrease in weightInsomnia or trouble sleepingIrritabilityJumpinessKeyed up or on edgeLack or loss of interest in thingsMemory ProblemsNervousnessRepetitive, senseless behaviorRepetitive, senseless thoughtsRestlessnessSad, depressed or down in the dumpsSeeing or hearing things that are not realSeizuresSkin rashSleeping too muchSweatingTensionTremors, trembling or shakinessTrouble making decisionsViolent behaviorWeaknessWorthless feelingsNO SYMPTOMS TO REPORTPhoneSubmit