| Attention: Physician Name |
| Mental Health Screener® Summary |
| Patient ID # : |
| Positive Screen |
| Disorder |
| Central Time |
| 09:34:19 AM |
| Assessment Time: |
| 03/08/2000 |
| Assessment Date: |
| 12345 |
| Mood |
| YES |
| Major Depressive Disorder |
| NO |
| Partial Remission of Major Depressive Disorder |
| YES |
| Dysthymia |
| NO |
| Minor Depressive Disorder |
| NO |
| Possible History of Bipolar Disorder |
| Anxiety |
| YES |
| Panic Disorder |
| YES |
| Generalized Anxiety Disorder |
| NO |
| Social Phobia - Generalized |
| NO |
| Social Phobia - Performance |
| YES |
| Obsessive Compulsive Disorder |
| NO |
| Anxiety Disorder NOS |
| Alcohol |
| YES |
| Probable Alcohol Abuse/Dependence |
| Eating |
| NO |
| Binge Eating Disorder |
| NO |
| Bulimia Nervosa, Purging Type |
| NO |
| Bulimia Nervosa, Non Purging Type |
| Suicidality |
| YES |
| Suicidal Ideation |
| NOTE: This report is not a substitute for clinical diagnosis, but is an adjunctive tool. |
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