Patient Health Questionnaire (Phq-9)
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1
2___ CA Medicaid
PATIENT HEALTH QUESTIONNAIRE (PHQ-9) + 3
___ Referred for Phone Protoco
l
Nine Symptom Checklist for Depression Screening
Name: ___________________________________________ DOB: _____________ Medicaid #: __________________
Practice #: ________________ Provider: ___________________________________ Diagnosis/ICD-9 Code: ________
Date of Initial Diagnosis: ___________________ Screening Date: __________________
Over the last 2 weeks how often have you been bothered by any of the following problems?
More than
Complete Questions 1 - 9 Initially then at all Critical Decision
Several
Nearly
Not at all
half the
Points (CDPs)
Days
every day
days
1. Little interest or pleasure in doing things
0
0
0
0
0
0
0
0
2. Feeling down, depressed, or hopeless
0
0
0
0
3. Trouble falling/staying asleep, sleeping too much
0
0
0
0
4. Feeling tired or having little energy
0
0
0
0
5. Poor appetite or overeating
0
0
0
0
6. Feeling bad about yourself-or that you are a failure or have let
yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or
0
0
0
0
watching television
8. Moving or speaking so slowly that other people could have noticed.
0
0
0
0
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 hurting yourself in
0
0
0
0
some way. (if positive, complete the Suicide Risk Assessment)
PHQ-9 Scoring Formula
# Symptoms
___ X 0 =
___ X 1 =
___ X 2 =
___ X 3 =
Per Category
______ +
_______ +
_______ +
_______ =
PHQ-9 Total Score:
_______
Q#1 was developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, & Colleagues. For research information contact Dr. Spitzer at rls8@columbia.edu.
10. If you checked off any problem on this questionnaire so far 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 at All
Somewhat
Somewhat Difficult
Very Difficult
Extremely Difficult
Complete Questions 11-12 at INITIAL VISIT ONLY
11. In the past two years, have you felt depressed or sad most days, even if you felt okay sometimes?
No
Yes
12. Has there ever been a period of at least four days when you were so happy, over energetic or irritable that you got into trouble,
or your family or friends worried about it or a doctor said you were manic?
No
Yes
Best Phone #: ________________
Ok to leave message? YES or NO
Note: ______________________
Medication: __________________
Dose: ______________________
Frequency: _________________
st
nd
1
copy to Medical Record
2
copy to Initiate Phone Protocol
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