PHQ-9 & GAD-7
Patient Health Questionnaire - 9 & Generalized Anxiety Disorder Screener - 7
Name
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First Name
Last Name
Today's Date:
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Date
Appointment Date:
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Provider:
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Cecilia Duplechan, PMHNP-BC
Stacy McGee-Wheat, , PMHNP-BC
Over the last 2 weeks, how often have you been bothered by the following problems? - (PHQ-9)
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
Over the last 2 weeks, how often have you been bothered by the following problems? (GAD-7)
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
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)
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Mood Disorder Questionnaire (MDQ)
This questionnaire should be used as a starting point. It is not a substitute for a full medical evaluation. Bipolar disorder is a complex illness, and an accurate, thorough diagnosis can only be made through a personal evaluation by your doctor.
Please complete:
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Yes
No
1. Has there ever been a period of time when:
…you were not your usual self (while not on drugs or alcohol)?
…you were so irritable that you shouted at people or started fights or
arguments?
…you felt much more self-confident than usual?
…you got much less sleep than usual and found you didn't really miss it?
…you were much more talkative or spoke faster than usual?
…thoughts raced through your head or you couldn't slow you mind down?
…you were so easily distracted by things around you that you had trouble
concentrating or staying on track?
…you had much more energy than usual?
…you were much more active or did many more things than usual?
…you were much more social or outgoing than usual; for example, you
telephoned friends in the middle of the night?
…you were much more interested in sex than usual?
…you did things that were unusual for you or that other people might
have thought were excessive, foolish, or risky?
…spending money got you or your family into trouble?
2. If you checked YES to more than one of the above, have several of
these ever happened during the same period of time?
3. Have any of your blood relatives had manic-depressive illness or
bipolar disorder?
4. Has a health professional ever told you that you have manic-
depressive illness or bipolar disorder?
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None
Minor
Moderate
Serious Problem
5.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? __ None __ Minor __ Moderate __ Serious problem
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ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist
Patient Name
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Today's Date
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Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, place an X in the box that best describes how you have felt and conducted yourself over the past 6 months. Please give this completed checklist to your healthcare professional to discuss during today’s appointment.
Never
Rarely
Sometimes
Often
Very Often
1. How often do you have trouble wrapping up the final details of a project, once thechallenging parts have been done?
2. How often do you have difficulty getting things in order when you have to do a task thatrequires organization?
3. How often do you have problems remembering appointments or obligations?
4. When you have a task that requires a lot of thought, how often do you avoid or delay gettingstarted?
5. How often do you fidget or squirm with your hands or feet when you have to sit down for along time?
6. How often do you feel overly active and compelled to do things, like you were driven by amotor?
7. How often do you make careless mistakes when you have to work on a boring or difficult project?
8.How often do you have difficulty keeping your attention when you are doing boring or repetitive work?
9.How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly?
10.How often do you misplace or have difficulty finding things at home or at work?
11.How often are you distracted by activity or noise around you?
12.How often do you leave your seat in meetings or other situations in which you are expected to remain seated?
13.How often do you feel restless or fidgety?
14.How often do you have difficulty unwinding and relaxing when you have time to yourself?
15.How often do you find yourself talking too much when you are in social situations?
16.When you’re in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves?
17.How often do you have difficulty waiting your turn in situations when turn taking is required?
18.How often do you interrupt others when they are busy?
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