Depression Assessment Rating Scale

Depression Rating Scale

PHQ-9
Are you currently a patient/client at Impireum?*

YesNo
Patient Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Today's Date*

MonthDayYear
Date of Visit
Date of Birth*

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

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

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

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

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

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

Not at allSeveral DaysMore than half 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 the daysNearly every day
9. Have you ever completed a trial of psychotherapy?*

YesNo
10. Have you ever completed two (2) or more trial of psychiatric medications?*

YesNo
11. Thoughts that you would be better off dead, or of hurting yourself*

Not at allSeveral DaysMore than half the daysNearly every day
PHQ-9 Calculation*
***Important: Follow-Up on Your PHQ-10 Assessment***

0–4: Normal

5–9: Mild

10 – 14: Moderate

15 - 19: Moderately Severe

20+: Severe

If Your PHQ-9 Depression Rating score is 10 or higher, we recommend you speak with a professional mental health provider.

An Impireum representative will reach out to you or register as a new patient.

Or please promptly contact a mental health provider for support.
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Depression Rating Scale