• PHQ-9 - PATIENT HEALTH QUESTIONNAIRE

  • Today's Date*
     . .
    2 digit month, 2 digit day, 4 digit year
  • Patient Date of Birth*
     . .
    2 digit month, 2 digit day, 4 digit year

  • 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*
  • 2. Feeling down, depressed, or hopeless*
  • 3. Trouble falling or staying asleep, or sleeping too much*
  • 4. Feeling tired or having little energy*
  • 5. Poor appetite or overeating*
  • 6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down*
  • 7. Trouble concentrating on things, such as reading the newspaper or watching television*
  • 8. Moving or speaking so slowly that other people could have noticed. Or the opposite - being so figety or restless that you have been moving around a lot more than usual*
  • 9. Thoughts that you would be better of dead, or of hurting yourself*
  • 10. If you checked of 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?*

  • Identity

  • Please select your preferred pronouns*
  • Can we use you preferred pronouns and preferred name in front of others in the room?*

  • Body Image

  • Do you worry about your weight or body composition?*
  • Do you limit or carefully control the foods that you eat?*
  • Do you try to lose weight to meet weight/image/appearance requirements in your sport?*
  • Does your weight affect the way you feel about yourself?*
  • Do you worry that you have lost control over how much you eat?*
  • Do you make yourself vomit or use diuretics or laxatives after you eat*
  • Do you currently have or have you ever suffered from an eating disorder?*
  • Do you ever eat in secret?*
  • Have you ever had a stress fracture?*
  • Are you concerned about acne?*
  • Are you concerned about excessive sweating?*

  • Females Only: 

  • Do you have monthly menstrual cycles?

  • Substance Abuse

    In the past YEAR, how many times have you used:

  • Tobacco?*
  • Alcohol?*
  • Marijuana?*
  • Prescription drugs that were not prescribed to you?*
  • Illegal Drugs?*
  • Inhalants?*
  • Herbs or synthetic drugs (such as salvia, ecstasy K2, or bath salts)?*
  •  
  • Should be Empty: