Patient Health Questionnaire-9

Please correct the errors described below.

Full Name

Date of Birth

Today's Date

ATTENTION: Must be filled out by person/patient being seen

(*Even if person/patient is a minor. Minor must be the one filling it out*)

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

1. Little interest or pleasure in doing things

Not at all [0] Several Days [1] More than Half the Days [2] Nearly Every Day [3]

2. Feeling down, depressed, or hopeless

Not at all [0] Several Days [1] More than Half the Days [2] Nearly Every Day [3]

3. Trouble falling or staying asleep, or sleeping too much

Not at all [0] Several Days [1] More than Half the Days [2] Nearly Every Day [3]

4. Feeling tired or having little energy

Not at all [0] Several Days [1] More than Half the Days [2] Nearly Every Day [3]

5. Poor appetite or overeating

Not at all [0] Several Days [1] More than Half the Days [2] Nearly Every Day [3]

6. Feeling bad about yourself or that you are a failure or have let yourself or your family down

Not at all [0] Several Days [1] More than Half the Days [2] Nearly Every Day [3]

7. Trouble concentrating on things, such as reading the newspaper or watching television

Not at all [0] Several Days [1] More than Half the Days [2] Nearly Every Day [3]

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

Not at all [0] Several Days [1] More than Half the Days [2] Nearly Every Day [3]

9. Thoughts that you would be better off dead or of hurting yourself in some way

Not at all [0] Several Days [1] More than Half the Days [2] Nearly Every Day [3]

For office coding

Total Score

If you checked off any problems, 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

FOR OFFICE USE ONLY

PHQ-9 Severity

Staff Initials

Score

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