Phq-9 Patient Health Questionnaire
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1
2Scoring Sheet for
Behavioral Health Screening Form
To Be Completed by Provider or Healthcare Professional
I. Depression: PHQ-9 PATIENT HEALTH QUESTIONNAIRE
Instructions: Add scores per column for questions 1-9,
More
Nearly
then add total score. Do not score question 10.
Not at
Several
than half
every
all
days
Scores of 0-4, no depression
the time
day
Scores of 5-9, mild depression
•
Scores of 10-14, moderate depression
•
Total columns
Scores of 15-19, moderately severe depression
•
Scores of 20-27, severe depression
Total score
•
•
Scores between 5 and 9 can be safely treated in the medical home setting by a primary care provider.
Refer for scores of 10 or higher.
•
Pay close attention to item 9, addressing suicidal thoughts. An answer of 3, “nearly every day”, warrants a referral
that should be classified as emergency and should receive a behavioral health assessment by the end of the
business day.
II. Anxiety: GAD-7 GENERAL ANXIETY QUESTIONNAIRE
Instructions: Add scores per column, then add total score.
More
Nearly
Not at
Several
than half
every
Scores of 0-4, minimal anxiety
all
days
the time
day
Scores of 5-9, mild anxiety
•
Scores of 10-14, moderate anxiety
•
Scores of 15-21, severe anxiety
Total columns
•
Total score
•
Refer for scores of 10 or higher.
III. Bipolar Disorder: MDQ – MOOD QUESTIONNAIRE
Instructions: Add scores for Question #1 (Yes=1, No=0).
Yes
No
A score of at least 7 is indicative of a possible bipolar spectrum disorder.
Consider the score in the context of a positive screen for depression on the
PHQ-9 for purposes of treatment of bipolar depression.
Total score Question 1
Refer if all the following criteria are met:
A score of 7 or higher to Question 1 AND “Yes” to Question 2 AND “Moderate” or “Serious” to Question 3
IV. Drug and Alcohol Abuse: SUBSTANCE USE QUESTIONNAIRE
Yes
No
Instructions: Add scores for all questions EXCEPT #1 and #15
(Yes=1, No=0). Questions 1 and 15 are not scored.
Total score
Refer for scores of 4 or higher.
Any suspicion that a clinician may have that a patient may have a thought disorder (auditory or visual hallucinations,
V. Thought Disorders
delusions/fixed, unfounded, unrealistic, and peculiar beliefs, etc.) warrants a referral for behavioral health services, or at the very
least a case conference between the behavioral health care manager and the Primary Care Provider or other designated medical
staff.
PROV-3B – Behavioral Health Scoring and Referral
- 1 -
(v5) 2/15/11
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