Patient Health Questionnaire (PHQ-9)

Please answer the questions and submit the form.

Please correct the errors described below.

This form is intended to screen for current symptoms of depression. It will assist with initial assessment as well as track ongoing progress.

Client Information

First name

Last name

Email address

Date

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

Little interest or pleasure in doing things?

Not at all Several days More than half the days Nearly every day

Feeling down, depressed, or hopeless?

Not at all Several days More than half the days Nearly every day

Trouble falling or staying asleep, or sleeping too much?

Not at all Several days More than half the days Nearly every day

Feeling tired or having little energy?

Not at all Several days More than half the days Nearly every day

Poor appetite or overeating?

Not at all Several days More than half the days Nearly every day

Feeling bad about yourself — or that you are a failure or have let yourself or your family down?

Not at all Several days More than half the days Nearly every day

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

Not at all Several days More than half the days Nearly every day

Moving or speaking so slowly that other people could have noticed? Or so fidgety or restless that you have been moving a lot more than usual?

Not at all Several days More than half the days Nearly every day

Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?

Not at all Several days More than half the days Nearly every day

If you checked off any problems, how difficult have those 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

24/7 support is available from The National Suicide Prevention Lifeline (1-800-273-8255) and the Crisis Text Line (text “HOME” to 741741; http://www.crisistextline.org/how-it-works/).

Your information will be encrypted.

This form is intended to screen for current symptoms of depression. It will assist with initial assessment as well as track ongoing progress.

Kristina Monroe, Psy.D.

Licensed Psychologist

323-546-7792
www.kristinamonroe.com
8235 Santa Monica Blvd., Suite 303, West Hollywood, CA, 90046

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