Form Phq-9 - Personal Health Questionnaire Depression Scale - Riverside Medical Group
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1
2Name: _______________________________
DOB: ________________________________
Date: ________________________________
Personal Health Questionnaire Depression Scale (PHQ-9)
More than
Nearly
How often during the past 2 weeks were you
Not at
Several
half the
every
bothered by …
all
days
days
day
0
1
2
3
Little interest or pleasure in doing things
1.
2. Feeling down, depressed, or hopeless
0
1
2
3
3. Trouble falling or staying asleep, or
0
1
2
3
sleeping too much
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 your 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 TV
8. Moving or speaking so slowly that other people could
have noticed. Or the opposite – being so fidgety or
0
1
2
3
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
Total Score: ________________
CAGE-AID Questionnaire
1. Have you ever felt that you ought to cut down on your drinking or drug
Yes
No
use?
2. Have people annoyed you by criticizing your drinking or drug use?
Yes
No
3. Have you ever felt bad or guilty about your drinking or drug use?
Yes
No
4. Have you ever had a drink or used drugs first thing in the morning to
Yes
No
steady your nerves or to get rid of a hangover?
Screening is: Positive / Negative
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