Patient Health Questionnaire-9 (Phq-9) Template/form Gad-7
ADVERTISEMENT
1
2
3
4
5
6
7
8P A T I E N T H E A L T H Q U E S T I O N N A I R E - 9
( P H Q - 9 )
Over the last 2 weeks, how often have you been bothered
More
Nearly
by any of the following problems?
Several
than half
every
✔
(Use “
” to indicate your answer)
Not at all
days
the days
day
1. Little interest or pleasure in doing things
0
1
2
3
2. Feeling down, depressed, or hopeless
0
1
2
3
3. Trouble falling or staying asleep, or sleeping too much
0
1
2
3
4. Feeling tired or having little energy
0
1
2
3
5. Poor appetite or overeating
0
1
2
3
6. Feeling bad about yourself — or that you are a failure or
0
1
2
3
have let yourself or your family down
7. Trouble concentrating on things, such as reading the
0
1
2
3
newspaper or watching television
8. Moving or speaking so slowly that other people could have
0
1
2
3
noticed? Or the opposite — being so fidgety or restless
that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead or of hurting
0
1
2
3
yourself in some way
0
+ ______ + ______ + ______
F
OR OFFICE CODING
______
=Total Score:
If you checked off any problems, how difficult have these problems made it for you to do your
work, take care of things at home, or get along with other people?
Not difficult
Somewhat
Very
Extremely
at all
difficult
difficult
difficult
Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from
Pfizer Inc.
No permission required to reproduce, translate, display or distribute.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical