PHQ-9 Adult
Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient #
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If you are currently in a relationship, please answer the below questions:
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Rows
Never
Rarely
Sometimes
Fairly Often
Frequently
How often does your partner physically hurt you?
How often does your partner in
sult you or talk down to you?
How often does your partner t
hreaten you with harm?
How often does your partner s
cream or curse at you
Sometimes things happen to people that are unusually or specially frightening, horrible, or traumatic. For example: A serious car accident or fire, physical or sexual assault/abuse, natural disaster, death of a loved one through homicide or suicide, or war. Have you ever experienced this kind of event
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Yes (If yes, please answer the questions below)
No
In the past month, have you:
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Rows
Yes
No
Had nightmares about the event(s) or thought about the event(s) when you did not want to?
Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)?
Been constantly on guard, watchful, or easily startled?
Felt numb or detached from others, activities, or surroundings?
Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems that event(s) may have caused?
How often have you been bothered by each of the following symptoms during the past 7 days?
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Rows
Not At All
Some 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 that you are a failure or 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 fidgety or restless that you have were moving around a lot more than usual?
9. Thoughts that you would be better off dead, or of hurting yourself in some way?
If you checked off any problems, how difficult have these problems made if for you to do your work, take care of things at home, or get along with other people?
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Not at all
Somewhat
Very
Extremely
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For Office Use Only
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Total/Partial Raw Score:
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Prorate Total Raw Score (if 1-2 items are unanswered)
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Provider Notes
Provider
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