PHQ-9 - PATIENT HEALTH QUESTIONNAIRE

PHQ-9 - PATIENT HEALTH QUESTIONNAIRE
Today's Date*

MonthDayYear
Date
Patient Full Name*
Patient Date of Birth*

MonthDayYear
Date
Over the last 2 weeks, how often have you been bothered by any of the following problems?
1. Little interest or pleasure in doing things*

Not at allSeveral daysMore than half of the daysNearly every day
2. Feeling down, depressed, or hopeless*

Not at allSeveral daysMore than half of the daysNearly every day
3. Trouble falling or staying asleep, or sleeping too much*

Not at allSeveral daysMore than half of the daysNearly every day
4. Feeling tired or having little energy*

Not at allSeveral daysMore than half of the daysNearly every day
5. Poor appetite or overeating*

Not at allSeveral daysMore than half of the daysNearly every day
6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down*

Not at allSeveral daysMore than half of the daysNearly every day
7. Trouble concentrating on things, such as reading the newspaper or watching television*

Not at allSeveral daysMore than half of the daysNearly every day
8. Moving or speaking so slowly that other people could have noticed. Or the opposite - being so figety or restless that you have been moving around a lot more than usual*

Not at allSeveral daysMore than half of the daysNearly every day
9. Thoughts that you would be better of dead, or of hurting yourself*

Not at allSeveral daysMore than half of the daysNearly every day
10. If you checked of 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 difficult at allSomewhat difficultVery difficultExtremely difficult
Identity
Please select your preferred pronouns*

she/her(s)he/him/histhey/them/their(s)
If different than your given name, what is your preferred name?
Can we use you preferred pronouns and preferred name in front of others in the room?*

YesNo
Body Image
Do you worry about your weight or body composition?*

YesNo
Do you limit or carefully control the foods that you eat?*

YesNo
Do you try to lose weight to meet weight/image/appearance requirements in your sport?*

YesNo
Does your weight affect the way you feel about yourself?*

YesNo
Do you worry that you have lost control over how much you eat?*

YesNo
Do you make yourself vomit or use diuretics or laxatives after you eat*

YesNo
Do you currently have or have you ever suffered from an eating disorder?*

YesNo
Do you ever eat in secret?*

YesNo
Have you ever had a stress fracture?*

YesNo
Are you concerned about acne?*

YesNo
Are you concerned about excessive sweating?*

YesNo
Females Only:
What age was your first menstrual cycle?
Do you have monthly menstrual cycles?

YesNo
How many menstrual cycles have you had in the last year (best guess)?
Substance Abuse

In the past YEAR, how many times have you used:
Tobacco?*

NeverOnce or TwiceMonthlyWeekly or more
Alcohol?*

NeverOnce or TwiceMonthlyWeekly or more
Marijuana?*

NeverOnce or TwiceMonthlyWeekly or more
Prescription drugs that were not prescribed to you?*

NeverOnce or TwiceMonthlyWeekly or more
Illegal Drugs?*

NeverOnce or TwiceMonthlyWeekly or more
Inhalants?*

NeverOnce or TwiceMonthlyWeekly or more
Herbs or synthetic drugs (such as salvia, ecstasy K2, or bath salts)?*

NeverOnce or TwiceMonthlyWeekly or more
Should be Empty: