Patient Health Questionnaire (PHQ-9)

Patient First Name

Patient Middle Name

Patient Last Name

Date

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. Feel 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 televison

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 hurting yourself in some way

Patient/Client First Name

Patient/Client Last Name

Patient/Client Signature

Date

PHQ9 Adult/Depression