Patient Health Questionnaire (PHQ9)
Name
First Name
Last Name
Date
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Over the last 2 weeks, how often have you been bothered by and of the following problems?
Not at all-0
Several Days-1
More than half the days-2
Nearly every day-3
1. Little interest or pleasure in doing things
1
2
3
4
2. Feeling down, depressed or hopeless
5
6
7
8
3. Trouble falling or staying asleep, sleeping too much
9
10
11
12
4. Feeling tired or having little energy
13
14
15
16
5. Poor appetite or overeating
17
18
19
20
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
21
22
23
24
7. Trouble concentrating on things, such as reading the newspaper or watching television
25
26
27
28
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
29
30
31
32
9. Thoughts that you would be better off dead, or of hurting yourself
33
34
35
36
Add Columns for Totals
Several Days
More than half the days
Nearly every day
Total:
0
/
100
If you check 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 difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Total:
0
/
100
Submit
Should be Empty: