Client Assessment Questionnaire

Client Name*

First NameLast Name

Date of Birth*

Date

In the LAST TWO WEEKS how often have you been bothered by any of the following problems?

	Not at all (0)	Several Days (1)	More than Half the Days (2)	Nearly Every Day (3)
1. Little interest or pleasure in things.
2. Feeling down, depressed, or hopeless.
3. Trouble falling 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 slowly that other people 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 hurting yourself in some way.

In the LAST TWO WEEKS how often have you been bothered by any of the following problems?

	Not at all (0)	Several Days (1)	More than Half the Days (2)	Nearly Every Day (3)
1. Feeling nervous, anxious, or on edge.
2. Not being able to stop or control worrying.
3. Worrying too much about different things.
4. Trouble relaxing.
5. Being so restless that it is hard to sit still.
6. Becoming easily annoyed or irritable.
7. Feeling afraid as if something awful might happen.

	No	Yes
Are you in any physical pain?

In your life, have you ever had any experience that was so frightening, horrible, or upsetting, that IN THE PAST MONTH YOU:

	No	Yes
1. Have had nightmares about it or thought about it when you did not want to?
2. Tried hard not to think about it or went out of the way to avoid situations that remind you of it?
3. Were constantly on guard, watchful, or easily startled?
4. Felt numb or detached from others, activities, or your surroundings?

In your life or IN THE PAST MONTH, when thinking about alcohol, drug use (include illegal drug use and the use of prescription drug use...)

	No	Yes
1. Have you felt that you ought to cut down on your drinking or drug use?
2. Have people annoyed you by criticizing your drinking or drug use?
3. Have you ever felt bad or guilty about drinking or drug use?
4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover?

Client Signature*

Today's Date*

Date

PHQ-9