The Patient Health Questionnaire (PHQ-9)
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Over the past two weeks, how often have you been bothered by any of the following problems:
Little Interest or pleasure in doing things:
0-not at all
1- Several Days
2- More Than Half the Days
3- Nearly Every Day
Feeling down, depressed or hopeless:
0- not at all
1- Several Days
2- More Than Half the Days
3- Nearly Every Day
Trouble falling asleep, staying asleep, or sleeping too much:
0- not at all
1- Several Days
2- More Than Half the Days
3- Nearly Every Day
Feeling tired or having little energy:
0- Not at all
1-Several Days
2- More Than Half the Days
3- Nearly Every Day
Poor Appetite or Overeating:
0- Not at all
1-Several Days
2-More than Half the Days
3- Nearly Every Day
Feeling bad about yourself- or that you're a failure or have let yourself or your family down down:
0- Not at all
1- Several Days
2-More Than Half the Days
3- nearly Every Day
Trouble concentrating on things, such as reading the newspaper or watching television
0-Not at all
1-Several Days
2-More Than Half the Days
3- Nearly Everyday
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 then usual:
0- Not at all
1-Several Days
2-More Than Half the Days
3- Nearly Everyday
Thoughts that you would be better off dead or hurting yourself in some way:
0- Not at all
1-Several Days
2-More than Half the Days
3-Nearly Everyday
Total added
If you checked off any problems, how difficult have those 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
Submit
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm