PATIENT HEALTH QUESTIONNAIRE-9
(PHQ-9)
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Over the last 2 weeks, how often have you been botheredby any of the following problems? (Use “✔” to indicate your answer)
*
Not at all
0
Several days
1
More than half the days
2
Nearly every day
3
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or 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 fidgety 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 in some way
FOR OFFICE CODING
0
+_____+_____+
_____
=Total Score_____
If you checked off any problems, how difficult have these problems made it for you to do yourwork, take care of things at home, or get along with other people?
*
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Submit
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