The Mental Health Questionnaire

Davenport Behavioral Center LLC

Experience compassionate care and effective solutions for your mental well-being.

Main Office: 321-663-6375
In case of an emergency call 911

Client Information

First name

Last name

Email address

Phone number

Patient Health Questionnaire (PHQ-9)

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 at all Several days More than half the days Nearly every day

How to Score the PHQ-9

Major depressive disorder (MDD) is suggested if:

• Of the 9 items, 5 or more are checked as at least ‘more than half the days’
• Either item 1 or 2 is checked as at least ‘more than half the days’

Other depressive syndrome is suggested if:

• Of the 9 items, between 2 and 4 are checked as at least ‘more than half the days’
• Either item 1 or 2 is checked as at least ‘more than half the days’

PHQ-9 scores can be used to plan and monitor treatment. To score the instrument, tally the numbers of all the checked responses under each heading (not at all=0, several days=1, more than half the days=2, and nearly every day=3). Add the numbers together to total the score on the bottom of the questionnaire.

Guide for interpreting PHQ-9 Scores

Functional Health Assessment

The instrument also includes a functional health assessment. This asks the patient how emotional difficulties or problems impact work, life at home, or relationships with other people. Patient response of ‘very difficult’ or ‘extremely difficult’ suggest that the patient’s functionality is impaired. After treatment begins, functional status and number score can be measured to assess patient improvement.

Note: Depression should not be diagnosed or excluded solely on the basis of a PHQ-9 score. A PHQ-9 score ≥ 10 has a sensitivity of 88% and a specificity of 88% for major depression.1 Since the questionnaire relies on patient self-report, the practitioner should verify all responses. A definitive diagnosis is made taking into account how well the patient understood the questionnaire, as well as other relevant information from the patient.

PHQ-9 is adapted from PRIME MD TODAY, developed by Drs Spitzer, Williams, Kroenke and colleagues, with an educational grant from Pfizer Inc. Use of the PHQ-9 may only be made in accordance with the Terms of Use available at www.pfizer.com. Copyright © 1999 Pfizer Inc. All rights reserved. PRIME MD TODAY is a trademark of Pfizer Inc.

Reference: Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613.

Generalized Anxiety Disorder (GAD-7)

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

Feeling nervous, anxious, or on edge?

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

Not being able to stop or control worrying?

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

Worrying too much about different things?

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

Trouble relaxing?

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

Being so restless that it's hard to sit still?

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

Becoming easily annoyed or irritable?

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

Feeling afraid as if something awful might happen?

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

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 at all Several days More than half the days Nearly every day

Mood Disorder Questionnaire (MDQ)

Select the answer that best applies to you

Has there ever been a period of time when you were not your usual self, and…

…you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?

Yes No

…you were so irritable that you shouted at people or started fights or arguments?

Yes No

…you felt much more self-confident than usual?

Yes No

…you were much more talkative or spoke faster than usual?

Yes No

…thoughts raced through your head or you couldn’t slow your mind down?

Yes No

…you were so easily distracted by things around you that you had trouble concentrating or staying on track?

Yes No

…you had much more energy than usual?

Yes No

…you were much more active or did many more things than usual?

Yes No

…you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?

Yes No

…you were much more interested in sex than usual?

Yes No

…you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?

Yes No

…spending money got you or your family in trouble?

Yes No

…you got much less sleep than usual and found you didn’t really miss it?

Yes No

2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time?

Please check 1 response only.

Yes, several have happened at the same time No, they do not happen at the same time

3. How much of a problem did any of these cause you — like being able to work; having family, money, or legal troubles; getting into arguments or fights?

Please check 1 response only.

No Problem Minor problem Moderate problem Serious problem

4. Have any of your blood relatives (i.e., children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?

Please check one response only.

Yes No Unsure

5. Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?

Please check one response only.

Yes No

This questionnaire should be used as a starting point. It is not a substitute for a full medical evaluation. Bipolar disorder is a complex illness, and an accurate, thorough diagnosis can only be made through a personal evaluation by your doctor.

Your information will be encrypted.

Frainelys Cruz - DNP, PMHNP

Psychiatric Nurse Practitioner - DNP, PMHNP, Davenport Behavioral Center LLC

Welcome to Davenport Behavioral Center, your trusted destination for comprehensive mental health evaluation, diagnosis, and treatment. Conveniently located in Champions Gate, Florida, our center offers a wide range of psychiatric services provided by Dr. Cruz, DNP—a highly experienced Psychiatrist and Psychiatric Mental Health Practitioner. With a decade of dedicated experience in the medical field, Dr. Cruz is double board certified in the state of Florida, specializing in psychiatry. Her passion for quality and individualized care ensures that each patient receives the utmost attention and support on their journey to mental health stability and wellness.

Main Office: 321-663-6375
Davenportbehavioralcenter.com
8390 Champions Gate Blvd suite 108, Championsgate, FL, 33896, United States