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Patient Health Questionnaire
This form should only be done on the day of your scheduled visit. PHQ9 & GAD7 Screening
20
Questions
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HIPAA
Compliance
1
Patient Name
*
This field is required.
First Name
Last Name
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2
Patient Date of Birth
*
This field is required.
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3
Feeling nervous, anxious or on edge
Not at all
Several Days
More than half the days
Nearly Every day
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4
Not being able to stop or control worrying
Not at all
Several Days
More than half the days
Nearly Every day
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5
Worrying too much about different things
Not at all
Several Days
More than half the days
Nearly Every day
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6
Trouble relaxing
Not at all
Several Days
More than half the days
Nearly Every day
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7
Being so restless that it is hard to sit still
Not at all
Several Days
More than half the days
Nearly Every day
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8
Becoming easily annoyed or irritable
Not at all
Several Days
More than half the days
Nearly Every day
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9
Feeling afraid as if something awful might happen
Not at all
Several Days
More than half the days
Nearly Every day
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10
GAD7 Total
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11
Over the last 2 weeks, I have had Little interest or pleasure in doing things
Not at all
Several days
More than half the days
Nearly Every day
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12
Over the last 2 weeks, I have been Feeling down, depressed, or hopeless
Not at all
Several days
More than half the days
Nearly Every day
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13
Over the last 2 weeks, I have had Trouble falling or staying asleep, or sleeping too much
Not at all
Several days
More than half the days
Nearly Every day
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14
Over the last 2 weeks, I have been Feeling tired or having little energy
Not at all
Several days
More than half the days
Nearly Every day
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15
Over the last 2 weeks, I have had a Poor appetite or overeating
Not at all
Several days
More than half the days
Nearly Every day
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16
Over the last 2 weeks, I have been Feeling bad about yourself – or that you are a failure or have let yourself or your family down
Not at all
Several days
More than half the days
Nearly Every day
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17
Over the last 2 weeks, I have had Trouble concentrating on things, such as reading the newspaper or watching television
Not at all
Several days
More than half the days
Nearly Every day
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18
Over the last 2 weeks, I have been Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual
Not at all
Several days
More than half the days
Nearly Every day
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19
Over the last 2 weeks, I have had Thoughts that I would be better off dead or of hurting yourself in some way
Not at all
Several days
More than half the days
Nearly Every day
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20
PHQ9 Total
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21
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?
Not difficult at All
Somewhat difficult
Very Difficult
Extremely difficult
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22
Scheduled Appointment Date
*
This field is required.
/
Date
Month
Day
Year
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23
Please sign your name
*
This field is required.
Clear
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24
Tags
Todo
In Progress
Done
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