Form Phq-9 - Patient Health Questionnaire Modified For Teens
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3Incorporating Mental Health
Screening Into Adolescent
Office Visits
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PHQ-9
Administering and Scoring the PHQ-9
Screening Questionnaire
Administering
Scoring
A Survey From Your Healthcare Provider —
PHQ-9 Modified for Teens
The Patient Health Questionnaire Modified
For every X:
for Teens (PHQ-9 Modified) can be used
Not at all = 0
Name ______________________________________________________________________ Clinician _______________________________________________
Medical Record or ID Number _______________________________________________ Date ____________________________________________________
with patients between the ages of 12 and
Several days = 1
Instructions: How often have you been bothered by each of the following symptoms during the past two weeks?
18 and takes less than five minutes to
For each symptom put an “X” in the box beneath the answer that best describes how you have been feeling.
More than half the days = 2
complete and score.
(0)
(1)
(2)
(3)
Nearly every day = 3
Not At
Several
More Than
Nearly
All
Days
Half the Days
Every Day
The PHQ-9 Modified can be administered
1. Feeling down, depressed, irritable, or hopeless?
Add up all “X”ed boxes on the screen.
2. Little interest or pleasure in doing things?
and scored by a nurse, medical technician,
3. Trouble falling asleep, staying asleep, or sleeping too much?
4. Poor appetite, weight loss, or overeating?
physician assistant, physician or other
5. Feeling tired, or having little energy?
Defining a Positive Screen on the
6. Feeling bad about yourself — or feeling that you are a failure, or
that you have let yourself or your family down?
office staff.
7. Trouble concentrating on things like school work, reading,
PHQ-9 Modified:
or watching TV?
8. Moving or speaking so slowly that other people could have
Patients should be left alone to complete
noticed?
Or the opposite — being so fidgety or restless that
Total scores ≥ 11 are positive
you were moving around a lot more than usual?
the PHQ-9 Modified in a private area, such
9. Thoughts that you would be better off dead, or of hurting
yourself in some way?
as an exam room or a private area of the
10. In the past year have you felt depressed or sad most days, even if you felt okay sometimes?
Yes
No
waiting room.
Suicidality:
11. If you are experiencing any of the problems on this form, 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 at all
Somewhat difficult
Very difficult
Extremely difficult
Patients should be informed of their
Regardless of the PHQ-9 Modified total
12. Has there been a time in the past month when you have had serious thoughts about ending your life?
Yes
No
confidentiality rights before the PHQ-9
score, endorsement of serious suicidal
13. Have you ever, in your whole life, tried to kill yourself or made a suicide attempt?
Yes
No
Modified is administered.
Score _____________________
FOR OFFICE USE ONLY
ideation OR past suicide attempt
Q. 12 and Q. 13 = Y or TS =≥11
(questions 12 and 13 on the screen)
The American Academy of Pediatrics and
Source: Patient Health Questionnaire Modified for Teens (PHQ-9) (Author: Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues)
PC/PHQ-9 Mod/6.4.10/1000
should be considered a positive screen.
the U.S. Preventive Services Task Force
recommends that depression screening be
conducted annually.
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