PHQ9

Name

First NameLast Name

Birth Date

MonthDayYear

Over the last 2 weeks, how often have you been bothered by 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
3a. Sleeping too much
4. Feeling tired or having little energy
5. Poor appetite
5a. 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.
8a. 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

10. If you checked off any problems, how difficult Not difficult at all have these problems made it for you to do your work, take care of things at home, or get along with other people?

PHQ-9 SCORE