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Patient Health Questionnaire
Name
First Name
Last Name
Today's date
-
Month
-
Day
Year
Date
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Rows
Not at all
Several days
More than half the days
Nearly everyday
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself - or that you are a failure or have let yourself or your family down
Trouble concentrating on thigs, such as reading the news or watching tv
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
Thoughts that you would be better of dead or of hurting yourself or others in some way
If you have checked off any 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 difficult at all
1
2
3
4
Extremely difficult
5
1 is Not difficult at all, 5 is Extremely difficult
Submit
Should be Empty: