Patient Health Questionnaire (PHQ-9)
Name
*
First Name
Last Name
Today's Date
*
-
Year
-
Month
Day
Date
Over the last 2 weeks, how often have you been bothered by the following problems?
Not at all
Several Days
More than half the days
Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so figety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself
Not difficult at all
Somewhat difficult
Very
difficult
Extremely
difficult
8. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Generalized Anxiety Disorder Screener (GAD-7)
Over the last 2 weeks, how often have you been bothered by the following problems?
Not at all
Several Days
More than half the days
Nearly every day
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
Not difficult at all
Somewhat difficult
Very
difficult
Extremely
difficult
8. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
When did the symptoms begin?
Please type your response above
Submit
For use by a healthcare professional:
PHQ-9 Score 0-4 Minimal 5-9 Mild 10-14 Moderate 15-19 Moderately-Severe 20+ Severe
GAD-7 Score 0-5 Minimal 6-10 Mild 11-15 Moderate 16-21 Severe
Should be Empty: