PHQ 9 - Adolescent

Patient First Name

Patient Middle Name

Patient Last Name

Date

Instructions: How often have you been bothered by each of the following symptoms during the past two weeks? For each symptom, choose beneath the answer that best describes how you have been feeling.

1. Feeling down, depressed, irritable, or hopeless?

0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly everyday

2. Little interest or pleasure in doing things?

0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly everyday

3. Trouble falling asleep, staying asleep, or sleeping too much?

0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly everyday

4. Poor appetite, weight loss or overeating?

0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly everyday

5. Feeling tired, or having little energy?

0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly everyday

6. Feeling bad about yourself - or feeling that you are a failure, or that you have let yourself or your family down?

0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly everyday

7. Trouble concentrating on things like school work, reading, or watching TV?

0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly everyday

8. Moving or speaking so slowly that other people could have noticed? Or the opposite - being to fidgety or restless that you were moving around a lot more than usual?

0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly everyday

9. Thoughts that you would be better off dead, or or hurting yourself in some way?

0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly everyday

In the past year, have you felt depressed or sad most days, even if you felt okay sometimes?

Yes
No

If you are experiencing any of the problems on this form, 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?

Yes
No

Has there been a time in the past month when you have had serious thoughts about ending your life?

Yes
No

Have you EVER, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?

Yes
No

Patient/Client Signature

Patient/Client Last Name

Patient/Client Signature

Date

PHQ9 Adolescent/Depression