Patient Health Questionnaire (PHQ-9)
Provided by: Wellness Grove
Legal Name
*
First Name
Middle Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Last 4 of SS#
*
Email Address
*
Confirmation Email
example@example.com
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BEGIN
PHQ-9
Over the last 2 weeks, how often have you been bothered by any of the following problems? (only check 1 box for each row)
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Not at all
Several days
More than half the days
Nearly every day
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself - or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
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
Thoughts that you would be better off dead, or of hurting yourself
Total Column 2
Total Column 3
Total Column 4
TOTAL SCORE
*
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
If you checked off any problems, 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?
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Next
Acknowledge & Sign
By signing this form electronically and clicking on "Sign & Submit", you are certifying that the information given on this form is true and correct to the best of your knowledge. Please note that an e-signature is the electronic equivalent of a hand-written (pen-and-paper) signature.
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Input Your Legal Name
*
Date
*
-
Month
-
Day
Year
Sign & Submit
Should be Empty: