PHQ-9 Form

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PHQ-9

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Date of Birth *

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

Not at all Several Days More than half the days Nearly every day

Little interest or pleasure in doing things
Not at allLittle interest or pleasure in doing things Not at all
Several DaysLittle interest or pleasure in doing things Several Days
More than half the daysLittle interest or pleasure in doing things More than half the days
Nearly every dayLittle interest or pleasure in doing things Nearly every day
Feeling down, depressed, or hopeless
Not at allFeeling down, depressed, or hopeless Not at all
Several DaysFeeling down, depressed, or hopeless Several Days
More than half the daysFeeling down, depressed, or hopeless More than half the days
Nearly every dayFeeling down, depressed, or hopeless Nearly every day
Trouble falling or staying asleep, or sleeping too much
Not at allTrouble falling or staying asleep, or sleeping too much Not at all
Several DaysTrouble falling or staying asleep, or sleeping too much Several Days
More than half the daysTrouble falling or staying asleep, or sleeping too much More than half the days
Nearly every dayTrouble falling or staying asleep, or sleeping too much Nearly every day
Feeling tired or having little energy
Not at allFeeling tired or having little energy Not at all
Several DaysFeeling tired or having little energy Several Days
More than half the daysFeeling tired or having little energy More than half the days
Nearly every dayFeeling tired or having little energy Nearly every day
Poor appetite or overeating
Not at allPoor appetite or overeating Not at all
Several DaysPoor appetite or overeating Several Days
More than half the daysPoor appetite or overeating More than half the days
Nearly every dayPoor appetite or overeating Nearly every day
Feeling bad about yourself – or that you are a failure or have let yourself or your family down
Not at allFeeling bad about yourself – or that you are a failure or have let yourself or your family down Not at all
Several DaysFeeling bad about yourself – or that you are a failure or have let yourself or your family down Several Days
More than half the daysFeeling bad about yourself – or that you are a failure or have let yourself or your family down More than half the days
Nearly every dayFeeling bad about yourself – or that you are a failure or have let yourself or your family down Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television
Not at allTrouble concentrating on things, such as reading the newspaper or watching television Not at all
Several DaysTrouble concentrating on things, such as reading the newspaper or watching television Several Days
More than half the daysTrouble concentrating on things, such as reading the newspaper or watching television More than half the days
Nearly every dayTrouble concentrating on things, such as reading the newspaper or watching television Nearly every day
Moving or speaking so slowly that others could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual
Not at allMoving or speaking so slowly that others could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual Not at all
Several DaysMoving or speaking so slowly that others could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual Several Days
More than half the daysMoving or speaking so slowly that others could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual More than half the days
Nearly every dayMoving or speaking so slowly that others could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way
Not at allThoughts that you would be better off dead or of hurting yourself in some way Not at all
Several DaysThoughts that you would be better off dead or of hurting yourself in some way Several Days
More than half the daysThoughts that you would be better off dead or of hurting yourself in some way More than half the days
Nearly every dayThoughts that you would be better off dead or of hurting yourself in some way Nearly every day

	Not at all	Several Days	More than half the days	Nearly every day
Little interest or pleasure in doing things	Not at allLittle interest or pleasure in doing things Not at all	Several DaysLittle interest or pleasure in doing things Several Days	More than half the daysLittle interest or pleasure in doing things More than half the days	Nearly every dayLittle interest or pleasure in doing things Nearly every day
Feeling down, depressed, or hopeless	Not at allFeeling down, depressed, or hopeless Not at all	Several DaysFeeling down, depressed, or hopeless Several Days	More than half the daysFeeling down, depressed, or hopeless More than half the days	Nearly every dayFeeling down, depressed, or hopeless Nearly every day
Trouble falling or staying asleep, or sleeping too much	Not at allTrouble falling or staying asleep, or sleeping too much Not at all	Several DaysTrouble falling or staying asleep, or sleeping too much Several Days	More than half the daysTrouble falling or staying asleep, or sleeping too much More than half the days	Nearly every dayTrouble falling or staying asleep, or sleeping too much Nearly every day
Feeling tired or having little energy	Not at allFeeling tired or having little energy Not at all	Several DaysFeeling tired or having little energy Several Days	More than half the daysFeeling tired or having little energy More than half the days	Nearly every dayFeeling tired or having little energy Nearly every day
Poor appetite or overeating	Not at allPoor appetite or overeating Not at all	Several DaysPoor appetite or overeating Several Days	More than half the daysPoor appetite or overeating More than half the days	Nearly every dayPoor appetite or overeating Nearly every day
Feeling bad about yourself – or that you are a failure or have let yourself or your family down	Not at allFeeling bad about yourself – or that you are a failure or have let yourself or your family down Not at all	Several DaysFeeling bad about yourself – or that you are a failure or have let yourself or your family down Several Days	More than half the daysFeeling bad about yourself – or that you are a failure or have let yourself or your family down More than half the days	Nearly every dayFeeling bad about yourself – or that you are a failure or have let yourself or your family down Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television	Not at allTrouble concentrating on things, such as reading the newspaper or watching television Not at all	Several DaysTrouble concentrating on things, such as reading the newspaper or watching television Several Days	More than half the daysTrouble concentrating on things, such as reading the newspaper or watching television More than half the days	Nearly every dayTrouble concentrating on things, such as reading the newspaper or watching television Nearly every day
Moving or speaking so slowly that others could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual	Not at allMoving or speaking so slowly that others could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual Not at all	Several DaysMoving or speaking so slowly that others could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual Several Days	More than half the daysMoving or speaking so slowly that others could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual More than half the days	Nearly every dayMoving or speaking so slowly that others could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way	Not at allThoughts that you would be better off dead or of hurting yourself in some way Not at all	Several DaysThoughts that you would be better off dead or of hurting yourself in some way Several Days	More than half the daysThoughts that you would be better off dead or of hurting yourself in some way More than half the days	Nearly every dayThoughts that you would be better off dead or of hurting yourself in some way Nearly every day

Thoughts that you would be better off dead or of hurting yourself in some way
Not at all
Several days
More than half the days
Nearly every day

	Yes	No
Do things ever feel so bad that you think about harming or killing yourself?	YesDo things ever feel so bad that you think about harming or killing yourself? Yes	NoDo things ever feel so bad that you think about harming or killing yourself? No
Do you ever feel that life is not worth living?	YesDo you ever feel that life is not worth living? Yes	NoDo you ever feel that life is not worth living? No
Have you ever made plans to end your life? If so, what?	YesHave you ever made plans to end your life? If so, what? Yes	NoHave you ever made plans to end your life? If so, what? No
Do you know how you would kill yourself? If so, how?	YesDo you know how you would kill yourself? If so, how? Yes	NoDo you know how you would kill yourself? If so, how? No
Have you made any actual preparations to kill yourself? If so, what?	YesHave you made any actual preparations to kill yourself? If so, what? Yes	NoHave you made any actual preparations to kill yourself? If so, what? No
Have you ever attempted suicide in the past? If so, how?	YesHave you ever attempted suicide in the past? If so, how? Yes	NoHave you ever attempted suicide in the past? If so, how? No
How likely is it that you would act on these thoughts/plans? (0-10, 10=certain)	YesHow likely is it that you would act on these thoughts/plans? (0-10, 10=certain) Yes	NoHow likely is it that you would act on these thoughts/plans? (0-10, 10=certain) No
Moving or speaking so slowly that others could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual	YesMoving or speaking so slowly that others could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual Yes	NoMoving or speaking so slowly that others could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual No
Thoughts that you would be better off dead or of hurting yourself in some way	YesThoughts that you would be better off dead or of hurting yourself in some way Yes	NoThoughts that you would be better off dead or of hurting yourself in some way No

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PHQ-9 Form

PHQ-9

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

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