Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7) Questionnaire

PHQ-9 / GAD-7

Please read each statement and select the response that best describes how you have been feeling during the past two weeks, including today.
Your provider has asked you to complete this form as a means to evaluate your current health status. Your provider will receive the completed form and may incorporate results in their progress notes. You will need the provider's name and email address to complete the form.
Today's Date

MonthDayYear
Date
Patient Name

Last NameFirst Name
Date of Birth

MonthDayYear

Over the last 2 weeks, how often have you been bothered by the following problems?

	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?

	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

Clinican's Name*

First NameLast Name
Credentials
NPI #
ProMedView Strategic Clinical Solutions - Building Resilience, Restoring Lives.
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)
Should be Empty:

PHQ-9 / GAD-7