Form Phq-4, An Ultra-Brief Screening Scale For Anxiety And Depression Page 2
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1
2Patient Health Questionnaire (PHQ-4)
Name: ____________________________________
Due Date/ Delivery Date: __________________
Today’s Date: _____________________________
Over the past 2 weeks
Several
More days
Nearly
have you been bothered
Not at all
days
than not
every day
by these problems?
Feeling nervous, anxious,
0
1
2
3
or on edge
Not being able to stop or
0
1
2
3
control worrying
Feeling down, depressed,
0
1
2
3
or hopeless
Little interest or pleasure in
0
1
2
3
doing things
The thought of harming myself has occurred to me (circle one)
No
Yes
Administered by (initial):
MD
CMA
Self
TOTAL
Notes:
Reviewing provider:
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Parent category: Medical