PHQ-9A

Patient name*

First NameLast Name

Patient date of birth*

Date

Who should form be sent to/who is your appointment with?*

Over the last two weeks, how often have you been bothered by any of the following problems?

	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 so 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?

Total score

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

**If you have had thoughts that you would be better off dead or of hurting yourself in some way, please discuss this with your Health Care Clinician, go to a hospital emergency room or call 911.