Patient Health Self-Assessment
The following Patient Health Questionnaire is a multipurpose self-assessment to assist your physician in screening, diagnosing, and measuring the severity of depression.
First Name:
*
Last Name:
*
Date of Birth:
*
-
Month
-
Day
Year
Email:
*
example@example.com
Address
*
City
*
State
*
Zip Code:
*
DBH Office Location Preference
*
Hanover, MA
Needham, MA
Either
1) Over the past two weeks, how often have you had little interest or pleasure in doing things?
*
Not at all
Several Days
More than half the days
Nearly every day
2) Over the past two weeks, have you been feeling down, depressed, or hopeless?
*
Not at all
Several days
More than half the days
Nearly every day
3) Over the past two weeks, have you had trouble falling or staying asleep, or sleeping too much?
*
Not at all
Several days
More than half the days
Nearly every day
4) Over the past two weeks, have felt tired or had little energy?
*
Not at all
Several days
More than half the days
Nearly every day
5) Over the past two weeks, have you had little appetite or overeating?
*
Not at all
Several days
More than half the days
Nearly every day
6) Over the past two weeks, have you been 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) Over the past two weeks, have you had 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) Over the past two weeks, have you been moving or speaking so slowly that other people could notice? Or the opposite - being so fidgety 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) Over the past two weeks, have you had 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
How many antidepressant prescription medications do you currently take or have tried in the past?
*
0
1
2-4
5+
Score:
SUBMIT
Should be Empty: