Depression and Anxiety Screening
PHQ-9 and GAD-7
Name
First Name
Last Name
Provider
Date
-
Month
-
Day
Year
Date
PHQ-9
How often have you been bothered by the following over the past 2 weeks?
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 so fidgety or restless that you have been moving a lot more than usual?
Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?
PHQ Score
Not at all
Somewhat difficult
Very difficult
Extremely difficult
How difficult have these problems made it to do work, take care of things at home, or get along with other people?
GAD-7
How often have you been bothered by the following over the past 2 weeks?
Not at all
Several days
More than half the days
Nearly every day
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's hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen
GAD-7 Score
Not at all
Somewhat difficult
Very difficult
Extremely difficult
How difficult have these problems made it to do work, take care of things at home, or get along with other people?
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