GAD-7 (General Anxiety Disorder-7)

PHQ-9

Depression Screening
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Today's Date*

MonthDayYear
Date
Over the last two weeks, how often have you been bothered by the following problems?
1. Little interest or pleasure in doing thing*

Not at all (0)Several days (+1)More than half the days (+2)Nearly every day (+3)
2. Feeling down, depressed, or hopeless*

Not at all (0)Several days (+1)More than half the days (+2)Nearly every day (+3)
3. Trouble falling or staying asleep, or sleeping too much*

Not at all (0)Several days (+1)More than half the days (+2)Nearly every day (+3)
4. Feeling tired or having little energy*

Not at all (0)Several days (+1)More than half the days (+2)Nearly every day (+3)
5. Poor appetite or overeating*

Not at all (0)Several days (+1)More than half the days (+2)Nearly every day (+3)
6. Feeling bad about yourself or that you are a failure or have let yourself or your family down*

Not at all (0)Several days (+1)More than half the days (+2)Nearly every day (+3)
7. Trouble concentrating on things, such as reading the newspaper or watching television*

Not at all (0)Several days (+1)More than half the days (+2)Nearly every day (+3)
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*

Not at all (0)Several days (+1)More than half the days (+2)Nearly every day (+3)
9. Thoughts that you would be better off dead, or of hurting yourself*

Not at all (0)Several days (+1)More than half the days (+2)Nearly every day (+3)
TOTAL
What range did your score fall under?

1–4: Minimal depression5–9: Mild depression10–14: Moderate depression15–19: Moderately severe depression20–27: Severe depression
If you checked any problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at allSomewhat difficultVery difficultExtremely difficult
Should be Empty:

PHQ-9

Over the last two weeks, how often have you been bothered by the following problems?