Patient Health Questionnaire (PHQ-9)

Name*

First Last

Date*

Date of birth*

Clinician*

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

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 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?*

Patient Health Questionnaire (PHQ-9)

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

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