Depression Screening Tool
by Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues
This is a screening measure to help you determine whether you might have depression that needs professional attention. This screening tool is not designed to make a diagnosis of depression but to be shared with your primary care physician or mental health professional to inform further conversations about diagnosis and treatment
Patient Name
*
First Name
Last Name
Email
*
Example: frontdesk@ffmh.us
Phone Number
*
Please enter a valid phone number. Add extension if you have one.
Format: (708) 852-5259 Ext 5251.
On a scale of 0 to 4, over the last two weeks, how often have you been bothered by any of the following problems?
*
Rows
0
1
2
3
4
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
If you clicked on any problems above, 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 all
Very difficult
Somewhat difficult
Extremely difficult
Date
*
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Patient Signature
*
Print Form
Submit
Submit
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: