PHQ-9M

Patient Name:*

Date of Birth:*

Date

Date of Assessment:*

Date

How often have you been bothered by each of the following symptoms during the past two weeks? For each symptom, put an “X” in the box beneath the answer that best describes how you have been feeling.

1. Feeling down, depressed, irritable, or hopeless?*

0 = Not at all1 = Several days2 = More than half the days3 = Nearly every day

2. Little interest or pleasure in doing things?*

0 = Not at all1 = Several days2 = More than half the days3 = Nearly every day

3. Trouble falling asleep, staying asleep, or sleeping too much?*

0 = Not at all1 = Several days2 = More than half the days3 = Nearly every day

4. Poor appetite, weight loss, or overeating?*

0 = Not at all1 = Several days2 = More than half the days3 = Nearly every day

5. Feeling tired, or having little energy?*

0 = Not at all1 = Several days2 = More than half the days3 = Nearly every day

6. Feeling bad about yourself or feeling that you are a failure, or that you have let yourself or your family down?*

0 = Not at all1 = Several days2 = More than half the days3 = Nearly every day

7. Trouble concentrating on things like school work, reading, or watching TV?*

0 = Not at all1 = Several days2 = More than half the days3 = 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 were moving around a lot more than usual?*

0 = Not at all1 = Several days2 = More than half the days3 = Nearly every day

9. Thoughts that you would be better off dead, or of hurting yourself in some way?*

0 = Not at all1 = Several days2 = More than half the days3 = Nearly every day

In the past year, have you felt depressed or sad most days, even if you felt okay sometimes?*

YesNo

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 allSomewhat difficultVery difficultExtremely difficult

Has there been a time in the past month when you have had serious thoughts about ending your life?

YesNo

Have you EVER, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?

YesNo

**If you have had thoughts that you would be better off dead or of hurting yourself in some way, please discuss this with your Health Care Clinician, go to a hospital emergency room, or call 911.

Total PHQ-9 Score

Scores range from 0 to 27. Higher scores indicate more severe depressive symptoms.

PHQ-9 Modified For Teens

How often have you been bothered by each of the following symptoms during the past two weeks? For each symptom, put an “X” in the box beneath the answer that best describes how you have been feeling.