PHQ- 9: Modified for Teens

Name

Date

Instructions: How often have you been bothered by each of the following symptoms during the past two weeks? For each symptom put an “X” in the box beneath the answer that best describes how you have been feeling.

	Not At All	Several Days	More Than Half the Days	Nearly Every Day
1. Feeling down, depressed, irritable, or hopeless?
2. Little interest or pleasure in doing things?
3. Trouble falling asleep, staying asleep, or sleeping too much?
4. Poor appetite, weight loss, or overeating?
5. Feeling tired, or having little energy?
6. Feeling bad about yourself-- or feeling that you are a failure, or that you have let yourself or your family down?
7. Trouble concentrating on things like school work, reading, or watching TV?
8. Moving or speaking so slowly that other people could have noticed? Or the opposite-- being do fidgety or restless that you were moving around a lot more than usual?
9. Thoughts that you would be better off dead, or of hurting yourself in some way?

In the past year have you felt depressed or sad most days, even if you felt okay sometimes?

YesNo

If you are experiencing any of the problems on this form, 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

Has there been a time in the past month when you have had serious thoughts about ending your life?

YesNo

Have you EVER in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?

YesNo