PHQ-9
See next section for GAD-7
Name
*
First Name
Last Name
Date
*
-
Year
-
Month
Day
Date
Over the last 2 weeks, how often have you been bothered by the following problems?
Rows
Not at all
Several Days
More than half the days
Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, sleeping too much
4. Feeling tired or 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 figety 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
GAD-7
See next section for MDQ
Over the last 2 weeks, how often have you been bothered by the following problems?
Rows
Not at all
Several Days
More than half the days
Nearly every day
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
Mood Disorder Questionnaire (MDQ)
Has there ever been a period of time when you were not your usual self and...
Rows
Yes
No
1. ...you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
2. ...you were so irritable that you shouted at people or started fights or arguments?
3. ...you felt much more self-confident than usual?
4. ...you got much less sleep than usual and found you didn’t really miss it?
5. ...you were much more talkative or spoke faster than usual?
6. ...thoughts raced through your head or you couldn’t slow your mind down?
7. ...you were so easily distracted by things around you that you had trouble concentrating or staying on track?
8. ...you had much more energy than usual?
9. ...you were much more active or did many more
things than usual?
10. ...you were much more social or outgoing than usual, for
example, you telephoned friends in the middle of the night?
11. ...you were much more interested in sex than usual?
12. ...you did things that were unusual for you or that other
people might have thought were excessive, foolish, or
risky?
13. ...spending money got you or your family into trouble?
14. If you checked YES to more than one of the above, have several of these ever happened during the same period of time?
Please Select
Yes
No
15. How much of a problem did any of these cause you — like being unable to work; having family, money, or legal troubles; getting into arguments or fights?
Please Select
No problem
Minor problems
Moderate problems
Serious problems
Submit
PHQ-9 Score (0-4 Minimal) (5-9 Mild) (10-14 Moderate) (15-19 Moderately-Severe) (20+ Severe)
GAD-7 Score (0-5 Minimal) (6-10 Mild) (11-15 Moderate) (16-21 Severe)
Should be Empty: