A Survey From Your Healthcare Provider Phq-9 Modified For Teens W Suicide Qs printable pdf download

A Survey From Your Healthcare Provider Phq-9 Modified For Teens W Suicide Qs

Name ___________________ Birthdate________ Doctor ________________ Today’s Date ________

A Survey from Your Healthcare Provider

Part of routine screening for your health includes considering mood and emotional concerns.

Instructions: How often have you been bothered by each of the following symptoms during the

past two weeks? For each symptom put an “X” in the box beneath the answer that best

describes how you have been feeling.

(0)

(1)

(2)

(3)

Not At All

Several Days

More Than

Nearly

Half the Days

Every Day

Feeling down, depressed, irritable or hopeless?

Little interest or pleasure in doing things?

Trouble falling or staying asleep or sleeping too much?

Poor appetite, weight loss, or overeating?

Feeling tired or having little energy?

Feeling bad about yourself --or feeling that you are a

failure, or have let yourself or your family down?

Trouble concentrating on things, like school work,

reading or watching TV?

Moving or speaking so slowly that other people could

have noticed?

Or the opposite – being so fidgety or restless that you

were moving around a lot more than usual?

Thoughts that you would be better off dead, or of

hurting yourself in some way?

In the past year have you felt depressed or sad most days, even if you felt OK sometimes?  Yes  No

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

Has there been a time in the past month when you have had serious thoughts

about ending your life?

 Yes  No

Have you ever, in your whole life, tried to kill yourself or made a suicide attempt?

 Yes  No

PHQ-‐9 M odified f or T

eens,

For Office Use Only: Score ______

A Survey From Your Healthcare Provider Phq-9 Modified For Teens W Suicide Qs

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