PHQ-9 modified for Adolescents (PHQ-A)
This form will take approximately 5 minutes to complete. Form to be completed by parent/ caregiver. Pediatric ACEs and Related Life Events Screener.
Child's Name:
First Name
Last Name
Clinician Name:
First Name
Last Name
Date
-
Month
-
Day
Year
Date
1. Feeling down, depressed, irritable, or hopeless?
*
Never
Rarely
Sometimes
Often
2. Little interest or pleasure in doing things?
*
Never
Rarely
Sometimes
Often
3. Trouble falling asleep, staying asleep, or sleeping too much?
*
Never
Rarely
Sometimes
Often
4. Poor appetite, weight loss, or overeating?
*
Never
Rarely
Sometimes
Often
5. Feeling tired, or having little energy?
*
Never
Rarely
Sometimes
Often
6. Feeling bad about yourself – or feeling that you are a failure, or that you have let yourself or your family down?
*
Never
Rarely
Sometimes
Often
7. Trouble concentrating on things like school work, reading, or watching TV?
*
Never
Rarely
Sometimes
Often
8. Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you were moving around a lot more than usual?
*
Never
Rarely
Sometimes
Often
9. Thoughts that you would be better off dead, or of hurting yourself in some way?
*
Never
Rarely
Sometimes
Often
In the past year have you felt depressed or sad most days, even if you felt okay sometimes?
Yes
No
If you are experiencing any of the problems on this form, 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
Somewhat difficult
Very difficult
Extremely difficult
Has there been a time in the past month when you have had serious thoughts about ending your life?
Yes
No
Have you EVER, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?
Yes
No
Signature:
*
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: