PHQ-9 & GAD-7 & QIDS-SR
*
First Name
Last Name
Date
*
-
Year
-
Month
Day
Date
Your current Clearwave Location
Garden City
Hauppauge
Latham
Middletown
Nanuet
New Rochelle
Poughkeepsie
Valhalla
Over the last 2 weeks, how often have you been bothered by the following problems?
*
Rows
Not at all
Several Days
More than half the days
Nearly every day
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
Over the last 2 weeks, how often have you been bothered by the following problems?
*
Rows
Not at all
Several Days
More than half the days
Nearly every day
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
PHQ-9 Score (0-4 Minimal) (5-9 Mild) (10-14 Moderate) (15-19 Moderately-Severe) (20+ Severe)
GAD-7 Score (0-5 Minimal) (6-10 Mild) (11-15 Moderate) (16-21 Severe)
During the past seven days...Falling Asleep
0. I never take longer than 30 minutes to fall asleep.
1. I take at least 30 minutes to fall asleep, less than half the time.
2. I take at least 30 minutes to fall asleep, more than half the time
3. I take more than 60 minutes to fall asleep, more than half the time.
During the past seven days... Sleep During the Night
0. I do not wake up at night
1. I have a restless, light sleep with a few brief awakenings each night.
2. I wake up at least once a night, but I go back to sleep easily
3. I awaken more than once a night and stay awake for 20 minutes or more, more than half the time.
During the past seven days... Waking Up Too Early:
0. Most of the time, I awaken no more than 30 minutes before I need to get up.
1. More than half the time, I awaken more than 30 minutes before I need to get up..
2. I almost always awaken at least one hour or so before I need to, but I go back to sleep eventually
3. I awaken at least one hour before I need to, and can't go back to sleep
During the past seven days...Sleeping Too Much:
0. I sleep no longer than 7-8 hours/night, without napping during the day
1. I sleep no longer than 10 hours in a 24-hour period including naps...
2. I sleep no longer than 12 hours in a 24-hour period including naps.
3. I sleep longer than 12 hours in a 24-hour period including naps.
During the past seven days...Feeling Sad:
0. I do not feel sad.
1. I feel sad less than half the time.
2. I feel sad more than half the time.
3. I feel sad nearly all of the time.
Please complete for Increased Appetite OR Decreased Appetite:
0. There is no change in my usual appetite.
1. I eat somewhat less often or lesser amounts of food than usual. OR I feel a need to eat more frequently than usual.
2. I eat much less than usual and only with personal effort. OR I regularly eat more often and/or greater amounts of food than usual.
3. I rarely eat within a 24-hour period, and only with extreme personal effort or when others persuade me to eat. OR I feel driven to overeat both at mealtime and between meals
Please complete for Decreased Weight OR Increased Weight:
0. I have not had a change in my weight
1. I feel as if I have had a slight weight loss. OR I feel as if I have had a slight weight gain.
2. I have lost 2 pounds or more. OR I have gained 2 pounds or more.
3. I have lost 5 pounds or more. OR I have gained 5 pounds or more.
During the past seven days...Concentration / Decision Making:
0. There is no change in my usual capacity to concentrate or make decisions.
1. I occasionally feel indecisive or find that my attention wanders.
2. Most of the time, I struggle to focus my attention or to make decisions.
3. I cannot concentrate well enough to read or cannot make even minor decisions.
During the past seven days...View of Myself
0. I see myself as equally worthwhile and deserving as other people.
1. I am more self-blaming than usual.
2. I largely believe that I cause problems for others.
3. I think almost constantly about major and minor defects in myself.
During the past seven days...Thoughts of Death or Suicide
0. I do not think of suicide or death.
1. I feel that life is empty or wonder if it's worth living.
2. I think of suicide or death several times a week for several minutes.
3. I think of suicide or death several times a day in some detail, or I have made specific plans for suicide or have actually tried to take my life.
During the past seven days...General Interest
0. There is no change from usual in how interested I am in other people or activities.
1. I notice that I am less interested in people or activities.
2. I find I have interest in only one or two of my formerly pursued activities.
3. I have virtually no interest in formerly pursued activities.
During the past seven days...Energy Level
0. There is no change in my usual level of energy.
1. I get tired more easily than usual.
2. I have to make a big effort to start or finish my usual daily activities (for example, shopping, homework, cooking, or going to work).
3. I really cannot carry out most of my usual daily activities because I just don't have the energy.
During the past seven days...Feeling Slow Downed
0. I think, speak, and move at my usual rate of speed.
1. I find that my thinking is slowed down or my voice sounds dull or flat.
2. It takes me several seconds to respond to most questions and I'm sure my thinking is slowed.
3. I am often unable to respond to questions without extreme effort.
During the past seven days...Feeling Restless
0. I do not feel restless.
1. I'm often fidgety, wringing my hands, or need to shift how I am sitting.
2. I have impulses to move about and am quite restless.
3. At times, I am unable to stay seated and need to pace around.
QIDS-SR (0-5 Normal) (6-10 Mild) (11-15 Moderate) (16-20 Severe) (20+ Very Severe)
The highest number of the first 4 questions
The highest number of question 14 OR 15
The highest number of the last two questions
Submit
Should be Empty: