Patient Health Questionnaire (PHQ-9)

Printed Patient's Legal Name(Required)
MM slash DD slash YYYY

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

A) Little interest or pleasure in doing things
B) Feeling down, depressed, or hopeless
C) Trouble falling/​staying asleep, sleeping too much
D) Feeling tired or having little energy
E) Poor appetite or overeating
F) Feeling bad about yourself or that you are a failure or have let yourself or your family down
G) Trouble concentrating on things, such as reading the newspaper or watching television.
H) 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.
I) Thoughts that you would be better off dead or of hurting yourself in some way
2) If you checked off any problem on this questionnaire sofar, 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?television.

PHQ-9* Questionnaire for Depression Scoring and Interpretation Guide

For physician use only

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.