Mental Health Questionnaires
Please complete the questions below. Your responses will be used by your medical provider to diagnose and determine the severity of your risks for depression and mental health disorders. Thank you!
Patient's Name
*
First Name
Last Name
Patient's Date of Birth
*
-
Month
-
Day
Year
Patient Health Questionnaire
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things.
*
Please Select
0 - Not at All
1 - Several Days
2 - More than Half the Days
3 - Nearly Every Day
Feeling down, depressed, or hopeless.
*
Please Select
0 - Not at All
1 - Several Days
2 - More than Half the Days
3 - Nearly Every Day
Trouble falling or staying asleep, or sleeping too much.
*
Please Select
0 - Not at All
1 - Several Days
2 - More than Half the Days
3 - Nearly Every Day
Feeling tired or having little energy.
*
Please Select
0 - Not at All
1 - Several Days
2 - More than Half the Days
3 - Nearly Every Day
Poor appetite or overeating.
*
Please Select
0 - Not at All
1 - Several Days
2 - More than Half the Days
3 - Nearly Every Day
Feeling bad about yourself - or that you are a failure or have let yourself or your family down.
*
Please Select
0 - Not at All
1 - Several Days
2 - More than Half the Days
3 - Nearly Every Day
Trouble concentrating on things, such as reading the newspaper or watching television.
*
Please Select
0 - Not at All
1 - Several Days
2 - More than Half the Days
3 - Nearly Every Day
Moving or spearking 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.
*
Please Select
0 - Not at All
1 - Several Days
2 - More than Half the Days
3 - Nearly Every Day
Thoughts that you would be better off dead or of hurting yourself in some way.
*
Please Select
0 - Not at All
1 - Several Days
2 - More than Half the Days
3 - 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?
*
Please Select
Not Difficult At All
Somewhat Difficult
Very Difficult
Extremely Difficult
Generalized Anxiety Disorder Questionnaire
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Feeling nervous, anxious, or on edge.
*
Please Select
0 - Not at All
1 - Several Days
2 - More than Half the Days
3 - Nearly Every Day
Not being able to stop or control worrying.
*
Please Select
0 - Not at All
1 - Several Days
2 - More than Half the Days
3 - Nearly Every Day
Worrying too much about different things.
*
Please Select
0 - Not at All
1 - Several Days
2 - More than Half the Days
3 - Nearly Every Day
Trouble relaxing.
*
Please Select
0 - Not at All
1 - Several Days
2 - More than Half the Days
3 - Nearly Every Day
Being so restless that it is hard to sit still.
*
Please Select
0 - Not at All
1 - Several Days
2 - More than Half the Days
3 - Nearly Every Day
Becoming easily annoyed or irritable.
*
Please Select
0 - Not at All
1 - Several Days
2 - More than Half the Days
3 - Nearly Every Day
Feeling afraid as it something awful might happen.
*
Please Select
0 - Not at All
1 - Several Days
2 - More than Half the Days
3 - 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?
*
Please Select
Not Difficult At All
Somewhat Difficult
Very Difficult
Extremely Difficult
Please sign to confirm that the information you provided is truthful and accurate.
*
Please verify that you are human.
*
Submit
Should be Empty: