PHQ-9 and GAD-7 Combo Health Questionnaire
PHQ-9 and GAD-7 Combo Health Questionnaire
Patient Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
PHQ-9
Over the last 2 weeks, how often have you been bothered by any of the following problems?
*
Rows
Not at all
0
Several days
1
More than half the days
2
Nealy every day
3
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 fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself in some way
.
*
Rows
Not at all
0
Several days
1
Over half the days
2
Nearly every day
3
Add the score for each column
TOTAL SCORE
*
.
*
Rows
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
If you checked any problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?
GAD-7
Over the last 2 weeks, how often have you been bothered by any of the following problems?
*
Rows
Not at all sure
0
Several days
1
Over half the days
2
Nearly every day
3
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it's hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
.
*
Rows
Not at all
0
Several days
1
Over half the days
2
Nearly every day
3
Add the score for each column
TOTAL SCORE
*
.
*
Rows
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
If you checked any problems, how difficult have they made it for you to do your work, take care of things at home, or get along with other people?
Submit
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