"Patient Health Questionnaire-9 Form"

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Developed by Drs. Robert L. Spitzer, Janet B.W. Williams,
Kurt Kroenke and colleagues, with an educational grant from Pfizer, Inc.
No permission required to reproduce, translate, display or distribute.
Patient Name______________________________DOB__________
Patient Signature ____________________________________ Date__________Time_________
Q
Patient Health Questionnaire-9 (PHQ-9)
O N N A I R E - 9 (PH - 9 ) )
Over the last 2 weeks, how often have you been
bothered by any of the following problems?
Nearly
Several
More than
every day
(Use “ ” to indicate your answer)
days
Not at all
half the days
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
0
1
2
3
or have let yourself or your family down
7. Trouble concentrating on things, such as reading the
0
1
2
3
newspaper or watching television
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
0
1
2
3
hurting yourself in some way
0
+
+
+
F
OR OFFICE CODING
=Total Score:
If you checked off any problems, 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
Somewhat
at all
difficult
Very difficult
Extremely difficult
520894en – REV 09/22/2015
PHQ-9
Assessment/Questionnaire
Enter score directly into Epic. Scan form to EHR.
Page 1 of 1
Developed by Drs. Robert L. Spitzer, Janet B.W. Williams,
Kurt Kroenke and colleagues, with an educational grant from Pfizer, Inc.
No permission required to reproduce, translate, display or distribute.
Patient Name______________________________DOB__________
Patient Signature ____________________________________ Date__________Time_________
Q
Patient Health Questionnaire-9 (PHQ-9)
O N N A I R E - 9 (PH - 9 ) )
Over the last 2 weeks, how often have you been
bothered by any of the following problems?
Nearly
Several
More than
every day
(Use “ ” to indicate your answer)
days
Not at all
half the days
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
0
1
2
3
or have let yourself or your family down
7. Trouble concentrating on things, such as reading the
0
1
2
3
newspaper or watching television
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
0
1
2
3
hurting yourself in some way
0
+
+
+
F
OR OFFICE CODING
=Total Score:
If you checked off any problems, 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
Somewhat
at all
difficult
Very difficult
Extremely difficult
520894en – REV 09/22/2015
PHQ-9
Assessment/Questionnaire
Enter score directly into Epic. Scan form to EHR.
Page 1 of 1