MM Follow Up + PHQ-9
Name: Date of Birth: Date:
Are you taking medications as prescribed? YesNo
How often do you miss a dose?
Time you go to bed:
Time you fall asleep:
How many times do you wake in the middle of the night?
Time you get up for the day?
Please CHECK any of these you have had since your last visit:
Alcohol Cannabis Tobacco Caffeine Meth/cocaine Pain pills/heroin Other
HEENT: headaches dry mouth blurred vision grinding/clenching teeth
Cardiac: heart palpitations racing heart chest pain
Respiratory: shortness of breath coughing wheezing
Stomach/bowel: nausea vomiting diarrhea constipation abdominal pain
Urinary: leakage hard to start stream burning frequent urge excessive urination
Musculoskeletal: joint pain muscle pain
Skin: rash itching excessive sweating acne hair loss excessive hair growth
Neuro: tremor/shakiness dizziness unsteadiness falls numbness/tingling slurred speech movements not done on purpose
Endocrine: change in sexual function change in menstrual cycle feeling too hot or too cold excessive thirst breast enlargement breast discharge
Blood/heme: easy bruising unusual bleeding
General: fever change in weight change in appetite
Over the last 2 weeks, how often have you been bothered by the following problems?
Little interest or pleasure in doing things:
0 - Not at all1 - Several days2 - Over half the days3 - Nearly every day
Feeling down, depressed or hopeless:
Trouble falling asleep, staying asleep or sleeping too much:
Feeling tired or having little energy:
Poor appetite or overeating:
Feeling bad about yourself, or that you are a failure or have let yourself or your family down:
Trouble concentrating on things such as reading or watching television:
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:
Thoughts of that you would be better off dead, or of hurting yourself in some way:
If so, how likely are you to act on these thoughts? UnlikelyLikely
If you checked off any problems from this list, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at allSomewhat difficultVery difficultExtremely difficult
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Document Name: MM Follow Up + PHQ-9
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