PHQ-9 Interpretation Form
Patient Name:
*
Date of Birth:
*
Date of Assessment:
*
Clinician/Provider Name:
*
Organization/Facility:
PHQ-9 Score Summary
PHQ-9 Score Summary
PHQ-9 Total Score
Depression Severity Interpretation
0-4
Minimal or None
5-9
Mild Depression Symptoms
10-14
Moderate Depression Symptoms
15-19
Moderately Severe Depression
20-27
Severe Depression
Total Score:
Severity Level:
Symptom Frequency Review
Symptom Frequency Review
Rows
Severity Notes
Little interest or pleasure
Feeling down/depressed/hopeless
Sleep disturbance
Fatigue/low energy
Appetite changes
Feelings of failure/guilt
Concentration difficulty
Psychomotor changes
Thoughts of death/self-harm
Functional Impact Assessment
Patient reports symptoms have made daily functioning:
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Areas Affected:
Work/School
Family Responsibilities
Relationships
Sleep
Allied Comfort N Care-Outpatient Mental Health Clinic | 236 W ALLEGHENY AVE PHILADELPHIA, PA 19133-3529 | 215-969-1771 | admin@alliedcomfortncare.com
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Appetite
Social Interaction
Self-Care
Other
Suicide Risk / Safety Screening
Question 9 Response:
"Thoughts that you would be better off dead or hurting yourself in some way"
Not at all
Several days
More than half the days
Nearly every day
Additional Risk Notes:
Immediate Safety Concerns:
None identified
Passive suicidal ideation
Active suicidal ideation
Safety plan discussed
Emergency referral recommended
Clinical Interpretation
Summary Interpretation:
Clinical Impression:
Minimal depressive symptoms
Adjustment/stress-related symptoms
Possible depressive disorder
Major depressive symptoms present
Further evaluation recommended
Allied Comfort N Care-Outpatient Mental Health Clinic | 236 W ALLEGHENY AVE PHILADELPHIA, PA 19133-3529 | 215-969-1771 | admin@alliedcomfortncare.com
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Recommended Next Steps
Monitor symptoms
Repeat PHQ-9 in weeks
Referral to therapy/counseling
Psychiatric evaluation recommended
Medication evaluation recommended
Crisis intervention/safety planning
Lifestyle/self-care interventions discussed
Follow-up appointment scheduled
Additional Recommendations:
Provider Signature
Provider Name:
*
Credentials:
*
Signature:
*
Date:
*
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Note: PHQ-9 is a screening instrument and should not be used alone to establish a diagnosis. Clinical judgment, patient history, and additional assessment are recommended.
Allied Comfort N Care-Outpatient Mental Health Clinic | 236 W ALLEGHENY AVE PHILADELPHIA, PA 19133-3529 | 215-969-1771 | admin@alliedcomfortncare.com
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