Self-Assessment Health Questionnaire
The following Patient Health Questionnaire is a multipurpose self-assessment to assist your physician in screening, diagnosing, and measuring the severity of depression.
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Over the last two weeks, how often have you been bothered by any of the following problems?
1. Little interest or pleasure in doing things
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
2. Feeling down, depressed, or hopeless
0 - Not at al
1 - Several days
2 - More than half the days
3 - Nearly every day
3. Trouble falling or staying asleep, or sleeping too much
0 - Not at al
1 - Several days
2 - More than half the days
3 - Nearly every day
4. Feeling tired or having little energy
0 - Not at al
1 - Several days
2 - More than half the days
3 - Nearly every day
5. Poor appetite or overeating
0 - Not at al
1 - Several days
2 - More than half the days
3 - Nearly every day
6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down
0 - Not at al
1 - Several days
2 - More than half the days
3 - Nearly every day
7. Trouble concentrating on things, such as reading the newspaper or watching television
0 - Not at al
1 - Several days
2 - More than half the days
3 - Nearly every day
8. Moving or speaking so slowly that other people could notice. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual
0 - Not at al
1 - Several days
2 - More than half the days
3 - Nearly every day
9. Thoughts that you would be better off dead, or of hurting yourself
0 - Not at al
1 - Several days
2 - More than half the days
3 - Nearly every day
How many anti-depressant prescription medications do you currently take or have tried in the past?
0
1
2-4
5+
No sure
Would you be interested in learning more about TMS, an FDA-cleared, non-drug treatment option that has been proven effective for people with depression?
*
Yes
No
Submit
Should be Empty: