Patient Health Questionnaire (Modified for Teens)
Essex Pediatrics • 89 Main Street, Essex Junction, VT 05452 • (802) 879-6556
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Today's Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Over the last two weeks, how often have you been bothered by the following problems?
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, Irritable or hopeless
3. Trouble falling asleep or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite, weight loss, 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 like school work, reading, or watching TV
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 in some way
Total Score
10. If you are experiencing any of the problems on this form, 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
11. In the past year, have you felt depressed or sad most days, even if you felt OK sometimes
*
Yes
No
12. Has there been a time in the post month when you have had serious thoughts about ending your life?
*
Yes
No
13. Have you ever, in your whole life, tried to kill yourself or made a suicide attempt
*
Yes
No
Submit
Should be Empty: