Minimum Data Set Questionnaire Phq-9 Template/form Gad-7
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1
2PATIENT NAME: _________________________________
DATE: _________________
PHQ-9
Over the last 2 weeks, how often have you been bothered by any
Not at all
Several
More
Nearly
of the following problems?
days
than half
every
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 have let
0
1
2
3
yourself or your family down
7 Trouble concentrating on things, such as reading the newspaper or
0
1
2
3
watching television
8 Moving or speaking so slowly that other people could have noticed?
0
1
2
3
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 yourself in
0
1
2
3
some way
PHQ9 total score:
Q6
I made plans to end my life in the last 2 weeks
NO
YES
CORE10
GAD-7
Over the last 2 weeks, how often have you been bothered by any
Not at all
Several
More
Nearly
of the following problems?
days
than half
every
the days
day
1 Feeling nervous, anxious or on edge
0
1
2
3
2 Not being able to stop or control worrying
0
1
2
3
3 Worrying too much about different things
0
1
2
3
4 Trouble relaxing
0
1
2
3
5 Being so restless that it is hard to sit still
0
1
2
3
6 Becoming easily annoyed or irritable
0
1
2
3
7 Feeling afraid as if something awful might happen
0
1
2
3
GAD7 total score:
Minimum Data Set (MDS) questionnaire
1
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Parent category: Medical