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:

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?

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?

Leave this empty:

Signature arrow

Signature Certificate
Document name: PHQ-9
lock iconUnique Document ID: da2f730a9dda42452b9c2ae36e8629adaba87c9b
Timestamp Audit
April 20, 2020 9:52 am PDTPHQ-9 Uploaded by Jason Dooley - IP
April 29, 2020 8:24 am PDTRecords Department - added by Jason Dooley - as a CC'd Recipient Ip:
April 29, 2020 9:35 am PDTCFD Main - added by Jason Dooley - as a CC'd Recipient Ip:
March 18, 2021 2:04 pm PDT Document owner has handed over this document to 2021-03-18 14:04:24 -
March 18, 2021 2:04 pm PDTCFD Main - added by Do Not Reply - as a CC'd Recipient Ip: