Patient Health Questionnaire (PHQ-9)
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Over the past two weeks, how often have you been bothered by any of the following problems?
Rows
Not at all
Several Days
More than half the days
Nearly everyday
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling asleep, staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself - or that you're a failure or that you have let yourself down 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 the opposite – being so fidgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better of dead or of hurting yourself in some way
If you checked off any problem on this questionnaire, how difficult have these problems made it for you to do your work, take care of things at home, or get along with people
Rows
Not Difficult at All
Somewhat Difficult
Very Difficult
Extremely Difficult
Check one
Submit
Should be Empty: