Patient Health Questionaire

Name

First NameLast Name

Clinician Name

First NameLast Name

Date

Instructions: How often have you been bothered by each of the following symptoms during the past two weeks? For each symptom select the circle in the box beneath the answer that best describes how you have been feeling.

Rows	Not At All	Several Days	More Than Half the Days	Nearly Everyday
Feeling down, depressed, irritable, or hopeless?
Little interest or pleasure in doing things?
Trouble falling asleep, staying asleep, or sleeping too much?
Poor appetite, weight loss, or overeating?
Feeling tired, or having little energy?
Feeling bad about yourself - or feeling that you are a failure, or that you have let yourself or your family down?
Trouble concentrating on things like school work, reading, or watching TV?
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?
Thoughts that you would be better off dead, or of hurting yourself in some way?

YesNo

Not DifficultSomewhat DifficultVery DifficultExtremely Difficult

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 healthcare clinician, go to the hospital emergency room or call 911.

Rows	Not at All	A Little Bit	Moderately	Quite a Bit	Extremely
Repeated, disturbing memories, thoughts, or images of a stressful experience from the past?
Repeated, disturbing dreams of a stressful experience from the past?
Suddenly acting or feeling as if a stressful experience from the past were happening again (as if you were reliving it)?
Feeling very upset when something reminded you of a stressful experience from the past?
Having physical reactions (e.g., heart pounding, trouble breathing, sweating) when something reminded you of a stressful experience from the past?
Avoiding thinking or talking about a stressful experience from the past or avoiding having feelings related to it?
Avoided activities or situations because they reminded you of a stressful experience from the past?
Having trouble remembering important parts of a stressful experience from the past?
Loss of interest in activities that you used to enjoy?
Feeling emotionally numb or being unable to have loving feelings for those close to you?
Feeling as if your future somehow will be cut short?
Having trouble falling or staying asleep?
Feeling irritable or having angry outbursts?
Difficulty concentrating?
Being “superalert” or watchful or on guard?
Feeling jumpy or easily startled?

Patient Health Questionaire

Abbreviated PCL