PHQ9-and-GAD7

Please Complete PHQ9 and GAD7
Which Heartland Christian Counseling office is your appointment in?

West Des MoinesPella
Date

MonthDayYear
Date
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
PHQ9

Over the last two weeks, how often have you been bothered by the following problems?
Little or no interest or pleasure in doing things

0 Not at all1 Several Days2 More than half the days3 Nearly every day
Feeling down, depressed, or hopeless

0 Not at all1 Several Days2 More than half the days3 Nearly every day
Trouble falling or staying asleep, sleeping too much

0 Not at all1 Several Days2 More than half the days3 Nearly every day
Feeling tired or having little energy

0 Not at all1 Several Days2 More than half the days3 Nearly every day
Poor appetite or overeating

0 Not at all1 Several Days2 More than half the days3 Nearly every day
Feeling bad about yourself- or that you are a failure or have let yourself or your family down

0 Not at all1 Several Days2 More than half the days3 Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television

0 Not at all1 Several Days2 More than half the days3 Nearly every day
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.

0 Not at all1 Several Days2 More than half the days3 Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way.

0 Not at all1 Several Days2 More than half the days3 Nearly every day
Total Score
Mild depression = 5-10

Moderate depression = 10-18

Severe depression = 19-27
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?

Not at all difficultSomewhat difficultVery difficultExtremely difficult
GAD7

Over the last two weeks, how often have you been bothered by the following problems?
Feeling nervous, anxious, or on edge

0 Not at all1 Several Days2 More than Half the Days3 Nearly Every Day
Not being able to stop or control worrying

0 Not at all1 Several Days2 More than Half the Days3 Nearly Every Day
Worrying too much about different things

0 Not at all1 Several Days2 More than Half the Days3 Nearly Every Day
Trouble relaxing

0 Not at all1 Several Days2 More than Half the Days3 Nearly Every Day
Being so restless that it's hard to sit still

0 Not at all1 Several Days2 More than Half the Days3 Nearly Every Day
Becoming easily annoyed or irritable

0 Not at all1 Several Days2 More than Half the Days3 Nearly Every Day
Feeling afraid as if something awful might happen

0 Not at all1 Several Days2 More than Half the Days3 Nearly Every Day
Total score
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?

Not at all difficultSomewhat difficultVery difficultExtremely difficult
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