PATIENT HEALTH QUESTIONAIRE-9
(PHQ - 9)
Name
*
First Name
Last Name
Over the last 2 weeks, how often have you been bothered
by any of the following problems?
1. Little interest or pleasure in doing things
*
1) Not at all
2) Several Days
3) More than half the days
4) Nearly everyday
2. Feeling down, depressed, or hopeless
*
1) Not at all
2) Several Days
3) More than half the days
4) Nearly everyday
3. Trouble falling or staying asleep, or sleeping too much
*
1) Not at all
2) Several Days
3) More than half the days
4) Nearly everyday
4. Feeling tired or having little energy
*
1) Not at all
2) Several Days
3) More than half the days
4) Nearly everyday
5. Poor appetite or overeating
*
1) Not at all
2) Several Days
3) More than half the days
4) Nearly everyday
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down
*
1) Not at all
2) Several Days
3) More than half the days
4) Nearly everyday
7. Trouble concentrating on things, such as reading the newspaper or watching television
*
1) Not at all
2) Several Days
3) More than half the days
4) Nearly everyday
8. 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
*
1) Not at all
2) Several Days
3) More than half the days
4) Nearly everyday
9. Thoughts that you would be better off dead or of hurting yourself in some way
*
1) Not at all
2) Several Days
3) More than half the days
4) Nearly everyday
If you checked off any problems, 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 all
Somewhat difficult
Very difficult
Extremely difficult
FOR OFFICE CODING:
Total Score
Current/Past Medical History
Have you ever had any prior Psychiatric Diagnosis, if Yes. What was your Diagnosis?
Please list any Past or Present Psychiatric Medications with Dosage and Frequency:
Please list any Past or Present Somatic Medications with Dosage and Frequency::
Any Allergies:
Any other Medical Conditions:
Do you have any current Court Cases? Or are you under any Probation Status?
Submit
Should be Empty: