Patient Health Questionnaire (PHQ-9)
Please answer these questions before your visit.
Name
*
First Name
Last Name
Visit date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Over the past 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
Little interest or pleasure in doing things.
Feeling down, depressed or hopeless.
Trouble falling asleep, staying asleep or sleeping too much.
Feeling tired or having little energy.
Poor appetite or overeating.
Feeling bad about yourself-- or that you're a failure or have let yourself or your family down.
Trouble concentrating on things, such as reading the newspaper or watching television.
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.
Thoughts that you would be better off dead or of hurting yourself in some way.
Score
You can discuss your score with your doctor.
How difficult have the problems you experienced 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
Back
Next
Have there been any changes to your medications?
No
Yes
Please describe the medication changes.
If you are filling out more than one questionnaire, you only need to do this part once.
Do you have access to your Patient Portal account?
Yes
No
I don't know
Please provide your email address so we can set-up your Patient Portal account. If you don't have an email address, just leave the space blank.
example@example.com
Signature
Submit
Should be Empty: