Mood & Wellness Questionnaires
Patient Name
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First Name
Last Name
Date of Birth:
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Month
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Day
Year
Date
Today's Date
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Month
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Day
Year
Date
Depression Screening Questionnaire
PHQ-9
Over the last 2 weeks, how often have you been bothered by any of the following problems?
1. Little interest or pleasure in doing things
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Not at all
Several days
More than half the days
Nearly every day
2. Feeling down, depressed, or hopeless
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Not at all
Several days
More than half the days
Nearly every day
3. Trouble falling or staying asleep, or sleeping too much
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Not at all
Several days
More than half the days
Nearly every day
4. Feeling tired or having little energy
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Not at all
Several days
More than half the days
Nearly every day
5. Poor appetite or overeating
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Not at all
Several days
More than half the days
Nearly every day
6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down
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Not at all
Several days
More than half the days
Nearly every day
7. Trouble concentrating on things, such as reading the newspaper or watching television
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Not at all
Several days
More than half the days
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 have been moving around a lot more than usual
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Not at all
Several days
More than half the days
Nearly every day
9. Thoughts that you would be better off dead, or of hurting yourself
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Not at all
Several days
More than half the days
Nearly every day
If you check off any problems, 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 all
Somewhat difficult
Very difficult
Extremely difficult
Total Score:
*
Scoring Guideline:
Total Score
Depression Severity
0-4
None
5-9
Mild
10-14
Moderate
15-19
Moderately Severe
20-27
Severe
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Anxiety Screening Questionnaire
GAD-7
Over the last 2 weeks, how often have you been bothered by any of the following problems?
1. Feeling nervous, anxious, or on edge
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Not at all
Several days
Over half the days
Nearly every day
2. Not being able to stop or control worrying
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Not at all
Several days
Over half the days
Nearly every day
3. Worrying too much about different things
*
Not at all
Several days
Over half the days
Nearly every day
4. Trouble relaxing
*
Not at all
Several days
Over half the days
Nearly every day
5. Being so restless that it's hard to sit still
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Not at all
Several days
Over half the days
Nearly every day
6. Becoming easily annoyed or irritable
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Not at all
Several days
Over half the days
Nearly every day
7. Feeling afraid as if something awful might happen
*
Not at all
Several days
Over half the days
Nearly every day
If you check off any problems, 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 all
Somewhat difficult
Very difficult
Extremely difficult
Total Score:
*
Scoring Guideline:
Total Score
Anxiety Degree of Severity
0-4
Minimal anxiety
5-9
Mild anxiety
10-14
Moderate anxiety
15-21
Severe anxiety
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Mood Patterns Screening Questionnaire
RMS
Have there been at least 6 different periods of time (at least 2 weeks) when you felt deeply depressed?
*
Yes
No
Did you have problems with depression before the age of 18?
*
Yes
No
Have you ever had to stop or change your antidepressant because it made you highly irritable or hyper?
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Yes
No
Have you ever had a period of at least 1 week during which you were more talkative than normal with thoughts racing in your head?
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Yes
No
Have you ever had a period of at least 1 week during which you felt any of the following: unusually happy; unusually outgoing; or unusually energetic?
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Yes
No
Have you ever had a period of at least 1 week which you needed much less sleep than usual?
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Yes
No
Total Score:
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Submit
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