Depression Screening Tool

This is a screening measure to help you determine whether you might have depression that needs professional attention. This screening tool is not designed to make a diagnosis of depression but to be shared with your primary care physician or mental health professional to inform further conversations about diagnosis and treatment.

On a scale of 0 to 4, over the last two weeks, how often have you been bothered by any of the following problems?

	0	1	2	3	4
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself--or that you are a failure or have let yourself or your family down
Trouble concentrating on things such as reading a book or watching television
Moving or speaking so slowly that other people could have notices; or the opposite—being so fidgety or restless that you have been moving around a lot more than unusual
Thoughts that you would be better off dead or of hurting yourself in some way

If you clicked on any problems above, how difficult have they 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 difficultSomewhat difficultVery difficultExtremely difficult

Patient Name

Signature

Date

Reference: Anxiety and Depression Association of America - Based on Patient Health Questionnaire-9 (PHQ-9) Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer Inc.