PHQ-9 Clinical Screening Form

PHQ-9 Clinical Screening Form

Complete your details and answer the 9 questions about the past 2 weeks; your total score and severity band will be calculated.
Please note: this form is not currently submitted through a HIPAA-compliant system, so confidentiality of your responses cannot be fully guaranteed in transit and storage. Please avoid including any information you would not want stored on a standard, non-HIPAA-compliant platform.
Create a confidential username
Date of Completion

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Over the last 2 weeks, how often have you been bothered by the following problems?

PHQ-9 Symptom Checklist

Rows	Not at all (0)	Several days (1)	More than half the days (2)	Nearly every day (3)
1) Little interest or pleasure in 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 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