Assessment: PHQ-9 (18 years and older)
Client Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Today's Date
-
Month
-
Day
Year
Date
Over the last 2 weeks, how often have you been bothered by any of the following problems?
1. Little interest or pleasure in doing things:
Please Select
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
2. Feeling down, depressed or hopeless:
Please Select
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
3. Trouble falling or staying asleep, or sleeping too much:
Please Select
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
4. Feeling tired or having little energy:
Please Select
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
5. Poor appetite or overeating:
Please Select
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
6. Feeling bad about yourself- or that you are a failure or have let yourself or your family down:
Please Select
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
7. Trouble concentrating on things, such as reading the newspaper or watching television:
Please Select
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
8. 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:
Please Select
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
9. Thoughts that you would be better off dead or of hurting yourself in some way:
Please Select
0 Not at all
1 Several days
2 More than half the days
3 Nearly every day
If you checked off any problem on this questionnaire so far, 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?
Please Select
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Submit
Should be Empty: