Mood & Anxiety Disorders

Mood and Anxiety
Disorders

Mood and anxiety disorders are very common.
The mortality risk is primarily
due to cardiovascular disease,
suicide and substance abuse.
Risk is highest early in the
course of treatment or within
two years of hospitalization.

Mood disorders are divided
into depressive disorders and
bipolar disorders. Anxiety
disorders include panic,
social phobia, generalized
anxiety disorders, obsessive
compulsive disorders and post
traumatic stress disorders.
Depressive disorders often
overlap with anxiety disorders
with recurrence common for
both.

Antidepressants, with
or without counseling,
are effective in treating
most individuals although
for more severe cases,
electroconvulsive therapy or
anti-psychotic agents may be
needed.

Important to know:

Clinical diagnosis
Date of diagnosis
Type of treatment
(medication, ECT,
counseling)
Any hospitalizations
Any suicide attempts or
thoughts
Any alcohol or drug abuse history

Helpful terms:

Benzodiazepines: Occasionally prescribed for anxiety, these drugs can be addicting: Xanax, Klonopin, Lorazepam and Valium are just a few. Caution is necessary when these drugs are prescribed.

Electroconvulsive Therapy (ECT): Electroconvulsive Therapy is formally known as electroshock therapy and is occasionally used for severe depression which has not responded to other treatment.

Contact Information

Name *

First

Last

Phone *

Email *

Date of Birth *

Height/Weight *

Gender (at birth) *

Male
Female

If "yes", provide information: *

Occupation(s): *

Exercise and/or recreational activities: *

Diagnosis/Treatment Information

Age Of First Diagnosis *

Type of Treatment: *

Has there been more than one episode (recurrent)? *

Is the insured taking any medications? *

If yes, please give details: *

Does the insured travel? *

If yes, where? *

How many hours per night, on average, does the insured sleep? *

Does the insured drink alcohol? *

If yes, how much and how frequently?

Has the insured used tobacco in the past 12 months? *

If yes, provide information:

Has the insured ever been hospitalized, seen in the emergency room or been on disability for psychiatric treatment of symptoms? *

If “YES,” please explain: *

Any suicide attempts or thoughts? *

If yes, please provide date and details of last incident: *

Has the insured ever missed work or school due to the disorder? *

Is there any history of drug or alcohol abuse? *

If yes, please provide details: *

Does the insured have any other major medical issues? *

If yes, please explain: *

Has the insured had any moving violations in the past three years? *