Patient Health Questionnaire

Patient Health Questionnaire (PHQ9)
Name

First Name Last Name
Date

Month Day Year
Email
example@example.com
Phone Number

Area Code Phone Number

Over the last 2 weeks, how often have you been bothered by and of the following problems?

Not at all-0

Several Days-1

More than half the days-2

Nearly every day-3

1. Little interest or pleasure in doing things

2. Feeling down, depressed or hopeless

3. Trouble falling or staying asleep, sleeping too much

4. Feeling tired or having little energy

5. Poor appetite or overeating

6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down

7. Trouble concentrating on things, such as reading the newspaper or watching television

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

9. Thoughts that you would be better off dead, or of hurting yourself

If you check 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

Total: 0 / 100
Should be Empty:

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Patient Health Questionnaire (PHQ9)