Patient Health Questionnaire-9 (PHQ-9)

Patient Health Questionnaire-9 (PHQ-9)

This form is designed to assess the severity of depression symptoms over the past two weeks.
Name

First NameLast Name
Date

MonthDayYear
Date
Over the past two weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things?*

Not at allSeveral daysMore than half the daysNearly every day
Feeling down, depressed, or hopeless?*

Not at allSeveral daysMore than half the daysNearly every day
Trouble falling or staying asleep, or sleeping too much?*

Not at allSeveral daysMore than half the daysNearly every day
Feeling tired or having little energy?*

Not at allSeveral daysMore than half the daysNearly every day
Poor appetite or overeating?*

Not at allSeveral daysMore than half the daysNearly every day
Feeling bad about yourself — or that you are a failure or have let yourself or your family down?*

Not at allSeveral daysMore than half the daysNearly every day
Trouble concentrating on things, such as reading the newspaper or watching television?*

Not at allSeveral daysMore than half the daysNearly every day
Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving a lot more than usual?*

Not at allSeveral daysMore than half the daysNearly every day
Please rate your overall depression severity based on your responses.*

1

2

3

4

5

6

7

8

9

10

1 is Minimum severity, 10 is Maximum severity
Additional comments or notes from you:
Should be Empty:

Patient Health Questionnaire-9 (PHQ-9)

Over the past two weeks, how often have you been bothered by any of the following problems?