PHQ-9

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:

0 - Not at all1 - Several days2 - Over half the days3 - Nearly every day

Trouble falling asleep, staying asleep or sleeping too much:

0 - Not at all1 - Several days2 - Over half the days3 - Nearly every day

Feeling tired or having little energy:

0 - Not at all1 - Several days2 - Over half the days3 - Nearly every day

Poor appetite or overeating:

0 - Not at all1 - Several days2 - Over half the days3 - Nearly every day

Feeling bad about yourself, or that you are a failure or have let yourself or your family down:

0 - Not at all1 - Several days2 - Over half the days3 - Nearly every day

Trouble concentrating on things such as reading or watching television:

0 - Not at all1 - Several days2 - Over half the days3 - Nearly every day

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 - Not at all1 - Several days2 - Over half the days3 - Nearly every day

Thoughts of that you would be better off dead, or of hurting yourself in some way:

0 - Not at all1 - Several days2 - Over half the days3 - Nearly every day

          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