PHQ9

FAMILY CONNECTIONS

Patient Health Questionnaire 9 (PHQ 9)
5891 Cedar Lake Road South, St. Louis Park, MN 55416

ph. 952-544-0964

fax 952-544-6405

www.familyconnectionsmn.com

PATIENT HEALTH QUESTIONNAIRE 9

All ages
Client Name *

First Name Last Name
Email *
example@example.com
Select your therapist *
Email of your therapist *
example@example.com
Date *

Month Day Year
Date

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

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 operating

6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down

7. Trouble concentration 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

Add Columns (all checked boxes in the first column = 0, all checked boxes in the second column = 1, all checked boxes in the third column = 2, all checked boxes in the fourth column = 3) *
Add Columns (all checked boxes in the first column = 0, all checked boxes in the second column = 1, all checked boxes in the third column = 2, all checked boxes in the fourth column = 3)
If you checked 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
For Office Use Only
For Clinician Use Only
Scoring: Count the number (#) of boxes checked in a column. Multiply that number by the value indicated below, then add the subtotal to produce a total score. The possible range is 0-27. Use the table below to interpret the PHQ-9 score.
Multiply the of total "Not at all" x 0 =
Multiply the total "Several days" x 1 =
Multiply the total "More than half the days" x 2 =
Multiply the total "Nearly every day" x 3 =
Total Score (add the four totals)
Parent or Guardian Name (if applicable)

First Name Last Name
Client Signature (or parent/guardian) *

Clear

Interpreting PHQ 9 Scores

Diagnosis	Total Score	For Score	Action
Minimal depression	0 - 4	≤ 4	The score suggests the patient may not need depression treatment
Mild depression Moderate depression	5 - 9 10 - 14	5 - 14	Physician uses clinical judgement about treatment, based on patient’s duration of symptoms and functional impairment
Moderate severe depression Severe depression	15 - 19	>14	Warrants treatment for depression, using antidepressant, psychotherapy and/or a combination of treatment.

Clinician Name

First Name Last Name
Clinician Signature

Clear
Date

Month Day Year
Date
Should be Empty:

FAMILY CONNECTIONS

PATIENT HEALTH QUESTIONNAIRE 9