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PHQ-9 (Patient Health Questionnaire-9)
This assessment should only take a few minutes.
11
Questions
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1
Hide provider information?
YES
NO
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2
What is your name?
*
This field is required.
First Name
Last Name
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3
Which Cornerstone provider asked you to complete this assessment?
Diane Maciejewski
Kim Loveland
Lynn Martin
Michelle Schrubbe
Janelle Prince
Not Listed
Diane Maciejewski
Kim Loveland
Lynn Martin
Michelle Schrubbe
Janelle Prince
Not Listed
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4
Provider's Email
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5
Over the last 2 weeks, how often have you been bothered by...
*
This field is required.
(Move the blue slider left or right to answer)
Little interest or pleasure in doing things?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Little interest or pleasure in doing things?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
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6
Over the last 2 weeks, how often have you been bothered by...
*
This field is required.
Feeling down, depressed or hopeless?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Feeling down, depressed or hopeless?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
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7
Over the last 2 weeks, how often have you been bothered by...
*
This field is required.
Trouble falling asleep, staying asleep, or sleeping too much?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Trouble falling asleep, staying asleep, or sleeping too much?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
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8
Over the last 2 weeks, how often have you been bothered by...
*
This field is required.
Feeling tired or having little energy?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Feeling tired or having little energy?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
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9
Over the last 2 weeks, how often have you been bothered by...
*
This field is required.
Poor appetite or overeating?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Poor appetite or overeating?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
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10
Over the last 2 weeks, how often have you been bothered by...
*
This field is required.
Feeling bad about yourself - or that you’re a failure or have let yourself or your family down?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Feeling bad about yourself - or that you’re a failure or have let yourself or your family down?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
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11
Over the last 2 weeks, how often have you been bothered by...
*
This field is required.
Trouble concentrating on things, such as reading the newspaper or watching television?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Trouble concentrating on things, such as reading the newspaper or watching television?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
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12
Over the last 2 weeks, how often have you been bothered by...
*
This field is required.
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?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
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?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
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Enter
13
Over the last 2 weeks, how often have you been bothered by...
*
This field is required.
Thoughts that you would be better off dead or of hurting yourself in some way?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Thoughts that you would be better off dead or of hurting yourself in some way?
Not at all
Several days
More than half the days
Nearly every day
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
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Submit
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Enter
14
Over the last 2 weeks, how often have you been bothered by...
*
This field is required.
Not at all
Several days
More than half the days
Nearly every day
Feeling nervous, anxious or on edge?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Not being able to stop or control worrying?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Worrying too much about different things?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Trouble relaxing?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Being so restless that it is hard to sit still?
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Becoming easily annoyed or irritable?
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Feeling afraid as if something awful might happen?
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Feeling nervous, anxious or on edge?
Not being able to stop 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?
Not at all
Row 0, Column 0
Several days
Row 0, Column 1
More than half the days
Row 0, Column 2
Nearly every day
Row 0, Column 3
Not at all
Row 1, Column 0
Several days
Row 1, Column 1
More than half the days
Row 1, Column 2
Nearly every day
Row 1, Column 3
Not at all
Row 2, Column 0
Several days
Row 2, Column 1
More than half the days
Row 2, Column 2
Nearly every day
Row 2, Column 3
Not at all
Row 3, Column 0
Several days
Row 3, Column 1
More than half the days
Row 3, Column 2
Nearly every day
Row 3, Column 3
Not at all
Row 4, Column 0
Several days
Row 4, Column 1
More than half the days
Row 4, Column 2
Nearly every day
Row 4, Column 3
Not at all
Row 5, Column 0
Several days
Row 5, Column 1
More than half the days
Row 5, Column 2
Nearly every day
Row 5, Column 3
Not at all
Row 6, Column 0
Several days
Row 6, Column 1
More than half the days
Row 6, Column 2
Nearly every day
Row 6, Column 3
1
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15
Total Score
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