Patient Health Questionnaire (PHQ)

Patient Health Questionnaire (PHQ)

PATIENT HEALTH QUESTIONNAIRE
Name*

First NameLast Name
Date*

MonthDayYear
Social Security Number (SSN)
Date of Birth (mm/dd/yyyy)*

MonthDayYear
Please check the number that best describes your answer to each question.

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Rows	(0) Not at all	(1) Several days	(2) More than half the days	(3) Nearly daily
1. Little interest or pleasure 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 fidgety 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 in some way?

Rows	Not difficult at all	Somewhat difficult	Very difficult	Extremely difficult
10. 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?

Rows	Yes	No
11. In the past two years, have you felt depressed or sad most days, even if you felt okay sometimes?
12. Have you been having thoughts of hurting yourself in some way?

F1021 / APPROVED FOR USE / 2107