PHQ-9

Name *

First

Last

Email *

ID Code (if known)

Have you had little interest or pleasure in doing things? *

0
1
2
3

Over a 2 week period.
0=Not at all 1=Several days 2=More than half the days 3=Nearly every day

Have you been feeling down, depressed or hopeless? *

0
1
2
3

Over a 2 week period.
0=Not at all 1=Several days 2=More than half the days 3=Nearly every day

Do you have trouble falling or staying asleep, or sleeping too much? *

0
1
2
3

Over a 2 week period.
0=Not at all 1=Several days 2=More than half the days 3=Nearly every day

Have you felt tired or had little energy? *

0
1
2
3

Over a 2 week period.
0=Not at all 1=Several days 2=More than half the days 3=Nearly every day

Have you had poor appetite or overeating? *

0
1
2
3

Over a 2 week period.
0=Not at all 1=Several days 2=More than half the days 3=Nearly every day

Have you been feeling bad about yourself or that you are a failure or have let yourself or family down? *

0
1
2
3

Over a 2 week period.
0=Not at all 1=Several days 2=More than half the days 3=Nearly every day

Have you had trouble concentrating on things such as reading a newspaper or watching television? *

0
1
2
3

Over a 2 week period.
0=Not at all 1=Several days 2=More than half the days 3=Nearly every day

Have you been 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? *

0
1
2
3

Over a 2 week period.
0=Not at all 1=Several days 2=More than half the days 3=Nearly every day

Have you had thoughts that you would be better off dead or thought of hurting yourself in some way? *

0
1
2
3

Over a 2 week period.
0=Not at all 1=Several days 2=More than half the days 3=Nearly every day

Please complete this PHQ-9 form if you have been asked to.