Depression Assessment (PHQ-9)

A copy of your results will be sent to you and to Multicare Specialists. Should your score indicate you are depressed, we may contact you to discuss available treatment options, including but not limited to ketamine infusion therapy.

Name*

Date of Birth*

Date

Email

example@example.com

Phone Number

Area CodePhone Number

The following questionnaire consists of 9 statements. Please read each group of statements carefully, and then pick out the one statement in each group that best describes the way you have been feeling during the past two weeks, including today. If several statements in the group seem to apply equally well, select the highest number for that group.

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

	Not At All	Several Days	More than half the days	Nearly Everyday
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired of 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 fidgety 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 in some way

If you checked off any of the above 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 At All	Several Days	More than half the days	Nearly Everyday
Check One