PATIENT HEALTH QUESTIONNAIRE
38 Winthrop Place, Staten Island, NY 10314
Service Date:
*
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Month
-
Day
Year
Date
Patient
*
First Name
Last Name
Over the last 2 weeks, how often have you beenbothered by any of the following problems?
*
Rows
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, or 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
Results
Rows
Several days
(Selected)
More than half the days
(Selected)
Nearly every day
(Selected)
Total Score
(Sum)
-
Rows
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or getalong with other
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