Name: Date of Birth:
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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Your legal name
Your email address
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Document Name: PHQ-9
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