12+ Year Screening Forms

PHQ-9 and CRAFFT Questionnaires
Name*

First Name Last Name
Date of birth*

MonthDay Year
Date
Patient Health Questionnaire (PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following problems?*

	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/staying asleep, 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 in some way.

If you checked off any problem on this questionnaire so far, 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
Difficulty

CRAFFT Questionnaire

During the PAST 12 MONTHS, on how many days did you:
1) Drink more than a few sips of beer, wine, or any drink containing alcohol? Put "0" if none.
Number* (# of Days)
2) Use any marijuana (weed, oil, or hash by smoking, vaping, or in food) or "synthetic marijuana" (like "K2", "Spice")? Put "0" none.
Number* (# of Days)
3) Use anything else to get high (like other illegal drugs, prescription, or over-the-counter medications, and things that you sniff/huff/vape)?
Number* (# of Days)
4) Have you ever ridden in a car driven by someone (including yourself) who was "high" or had been using alcohol or drugs?*

YesNo
5) Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?*

YesNo
6) Do you ever use alcohol or drugs while you are by yourself or alone?*

YesNo
7) Do you ever forget things you did while using alcohol or drugs?*

YesNo
8) Does your family or friends ever tell you that you should cut down on youyr drinking or drug use?*

YesNo
9) Have you ever gotten into trouble while you were using alcohol or drugs?*

YesNo
Should be Empty:

PHQ-9 and CRAFFT Questionnaires

Patient Health Questionnaire (PHQ-9)

CRAFFT Questionnaire