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> Patient Health Questionnaire (PHQ-9)
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Patient Health Questionnaire (PHQ-9)
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Patient Health Questionnaire (PHQ-9)
Name
*
First
Last
Date
*
DD slash MM slash YYYY
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?
*
None
Mild
Moderate
Moderately Severe
Severe
Feeling down, depressed, or hopeless?
*
None
Mild
Moderate
Moderately Severe
Severe
Trouble falling or staying asleep, or sleeping too much?
*
None
Mild
Moderate
Moderately Severe
Severe
Feeling tired or having little energy?
*
None
Mild
Moderate
Moderately Severe
Severe
Poor appetite or overeating?
*
None
Mild
Moderate
Moderately Severe
Severe
Feeling bad about yourself - or that you are a failure or have let yourself or your family down?
*
None
Mild
Moderate
Moderately Severe
Severe
Trouble concentrating on things, such as reading the newspaper or watching television?
*
None
Mild
Moderate
Moderately Severe
Severe
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?
*
None
Mild
Moderate
Moderately Severe
Severe
Thoughts that you would be better off dead, or of hurting yourself in some way?
*
None
Mild
Moderate
Moderately Severe
Severe
Δ
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