PHQ-9 for Teens

PHQ-9 for Teens
Name *

First Name Last Name
DOB *

Month Day Year
Date
Today's Date *

Month Day Year
Date
Instructions

How often have you been bothered by each of the following symptoms during the past two weeks? For each symptom, mark the box that best describes how you have been feeling.

	Not At All	Several Days	Over Half the Days	Nearly Every Day
1. Feeling down, depressed, irritable or hopeless
2. Little interest or pleasure in doing things?
3. Trouble falling asleep, staying asleep or sleeping too much?
4. Poor appetite, weight loss or overeating?
5. Feeling tired or having little energy?
6. Feeling bad about yourself - or feeling that you are a failure, having let yourself or your family down?
7. Trouble concentrating on things like school work, reading or watching TV?
8. Moving or speaking so slowly that other people could have noticed? -- or the opposite - being so fidgety or restless that you were moving around a lot more than usual?
9. Thoughts that you would be better off dead or of hurting yourself in some way?

In the past year have you felt depressed or sad most days, even if you felt okay sometimes? *

Yes No
If you are experiencing any of the problems on this form, 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
Has there been a time in the past month when you had serious thoughts about ending your life? *

Yes No
Have you ever, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt? *

Yes No
**If you have had thoughts that you would be better off dead or of hurting yourself in some way, please discuss this with your Health Care Clinician, go to a hospital Emergency Room or call 911.
Modified with permission by the GLAD-PC team from the PHQ-9 (Spitzer, Williams, & Kroenke, 1999), Revised PHQ-A (Johnson, 2002), and the CDS (DISC Development Group, 2000)
Score
Should be Empty:

Instructions