Patient Health Questionnaire (PHQ-9)

Name*

First NameLast Name

Date*

Date

Over the last 2 weeks, how often have you been bothered by any of the following problems? Type the point value for your choice in each question and leave the other boxes for that question blank. For example, if you chose "several days" for question 2, type a 1 in that box and leave the others blank.*

	Not at all 0 points each	Several Days 1 point each	More than half the days 2 points each	Nearly every day 3 points each
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 cold have noticed. Or the opposite - being so figety 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

*

	Not at all	Several Days	More than half the days	Nearly every day
Add up each column from above

Add up the 4 columns and put your answer here:*

10. If you checked off any problems in the table above, 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
Your answer

A2663B 10-04-2005