Behavioral Health Questionnaire(PHQ-9, GAD-7)

The Patient Health Questionnaire (PHQ-9)
Patient 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? *

	Not At All	Several Days	More than Half the Days	Nearly Every Day
Little interest or pleasure in doing things
Feeling down depressed or hopeless
Trouble falling sleep, staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself – or that you’re a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
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
Thoughts that you would be better off dead or of hurting yourself in some way

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
For Office Use Only
GAD-7 Anxiety

Over the past two weeks, how often have you been bothered by any of the following problems? *

	Not At All	Several Days	More than Half the Days	Nearly Every Day
Feeling nervous, anxious, or on edge
Not being able to sleep or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid, as if something awful might happen

For Office Use Only
For Office Use Only - D
For Office Use Only - A
For Office Use Only - S
Should be Empty: