THEZ07 Patient Health Questionnaire-9

Therapeutic Medical & Psychiatric Services LLC

PATIENT HEALTH QUESTIONNAIRE-9

(PHQ-9)
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Date

MonthDayYear
Date
Over the past 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 watchingtelevision?
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?
Calculation
10. 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?
Developed by Drs. Robert L Spitzer, Janet B. W. Williams, Kurt Kroenke and colleagues with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.
Should be Empty:

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