PHQ-9
Patient Health Questionnaire: English Version
Today's date
*
-
Month
-
Day
Year
Patient Name
*
First Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Over the last two weeks, how often have you been bothered by the following problems?
1. Little interest or pleasure in doing things
*
Not at all
Several Days
More than half the days
Nearly every day
2. Feeling down, depressed or hopeless
*
Not at all
Several Days
More than half the days
Nearly every day
3. Trouble falling or staying asleep, sleeping too much
*
Not at all
Several Days
More than half the days
Nearly every day
4. Feeling tired or having little energy
*
Not at all
Several Days
More than half the days
Nearly every day
5. Poor appetite or overeating
*
Not at all
Several Days
More than half the days
Nearly every day
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
*
Not at all
Several Days
More than half the days
Nearly every day
7. Trouble concentrating on things, such as reading the newspaper or watching television
*
Not at all
Several Days
More than half the days
Nearly every day
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
*
Not at all
Several Days
More than half the days
Nearly every day
9. Thoughts that you would be better off dead, or of hurting yourself
*
Not at all
Several Days
More than half the days
Nearly every day
PHQ-9 Calculation
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
Would you be interested in learning about Neurostar TMS, an FDA-cleared, non-drug treatment option that has been proven effective for people with depression?
*
Yes
No
How many anti-depressant medications do you currently take or have tried in the past?
0
1
2
3
4
5+
Submit
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