Depression Screening Questionnaire
(PHQ-9)
Patient Name
*
First Name
Last Name
Date of Birth:
*
/
Month
/
Day
Year
Date
Today's Date
*
/
Month
/
Day
Year
Date
Over the last 2 weeks, how often have you been bothered by any of the following problems?
1. Little interest or pleasure in doing things
*
Not at all
Several days
More than half the days
Nearly every day
2. Feeling down, depressed, or hopeless
*
Not at all
Several days
More than half the days
Nearly every day
3. Trouble falling or staying asleep, or sleeping too much
*
Not at all
Several days
More than half the days
Nearly every day
4. Feeling tired or having little energy
*
Not at all
Several days
More than half the days
Nearly every day
5. Poor appetite or overeating
*
Not at all
Several days
More than half the days
Nearly every day
6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down
*
Not at all
Several days
More than half the days
Nearly every day
7. Trouble concentrating on things, such as reading the newspaper or watching television
*
Not at all
Several days
More than half the days
Nearly every day
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
*
Not at all
Several days
More than half the days
Nearly every day
9. Thoughts that you would be better off dead, or of hurting yourself
*
Not at all
Several days
More than half the days
Nearly every day
If you check off any problems, 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?
*
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Submit
Total Score:
*
Scoring Guideline:
Total Score
Depression Severity
0-4
None
5-9
Mild
10-14
Moderate
15-19
Moderately Severe
20-27
Severe
Should be Empty: