Patient Health Questionnaire-9 Modified (PHQ-9)

Patient Health Questionnaire-9 Modified
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
Date

How often have you been bothered by each of the following symptoms during the past two weeks? For each symptom, select the answer that best described how you have been feeling.

Rows	Not At All	Several Days	More Than Half the Days	Nearly Every Day
Little interest or pleasure in doing things?
Feeling down, depressed, irritable, or hopeless?
Trouble falling asleep, staying asleep, or sleeping too much?
Feeling tired, or having little energy?
Poor appetite, weight loss, or overeating?
Feeling bad about yourself - or feeling that you are a failure, or that you have let yourself or your family down?
Trouble concentrating on things like school work, reading, or watching TV?
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?
Thoughts that you would be better off dead, or of hurting yourself in some way?

If you are experiencing any of the problems we just asked about, 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?
In the past year have you felt depressed or sad most days, even if you felt okay sometimes?
How often have you been bothered by the following symptom during the past two weeks: 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 ?
How often have you been bothered by the following symptom during the past two weeks: Thoughts that you would be better off dead, or of hurting yourself in some way?
Has there been a time in the past month when you have had serious thoughts about ending your life?
Have you EVER, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?
If you are thinking now of harming yourself please call 988, 911, talk to your doctor immediately, or go to the Emergency Department.
Not at All = 0, Several Days = +1, More than half the days +2, Nearly every day = +3
Score
Should be Empty:

Patient Health Questionnaire-9 Modified

Not at All = 0, Several Days = +1, More than half the days +2, Nearly every day = +3