Patient Health Questionnaire (PHQ-9)
Patient Name
First Name
Last Name
Date of Visit
-
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
1. Little Interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling asleep, 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 and your family
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.
Column Totals
Not at All = 0; Several Days = 1; More Than Half the Days = 2; Nearly Every Day = 3
Total of 0s
Total of 1s
Total of 2s
Total of 3s
Add Totals Together
10. 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