Fillable Printable Health Questionnaire Form - Montana
Fillable Printable Health Questionnaire Form - Montana
Health Questionnaire Form - Montana
PATIENT HEALTH QUESTIONNAIRE-9
(PHQ-9)
Over the last 2 weeks, how often have you been bothered
by any of the following problems?
(Use “
✔
” to indicate your answer)
Not at all
Several
days
More
than half
the days
Nearly
every
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 fall ing or staying asleep, or sleeping too muc h
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 b ad about your self — or that you are a failure or
have let yourself or your family down
0 1 2 3
7. Trouble concentrating on things, s uch as reading the
newspaper or watching television
0 1 2 3
8. Mov i ng or speaking so slowly that other people could have
noticed? Or the opposite — being so fidgety or restless
that you have been moving around a lot more than usual
0 1 2 3
9. Thoughts that you would be better off dead or of hurting
yourself in some way
0 1 2 3
FOR OFFICE CODING 0 + ______ + ______ + ______
=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
at all
Somewhat
difficult
Very
difficult
Extremely
difficult
Developed by Drs. Robert L. Spitzer, Jan et B.W. Williams, Ku rt Kroenke and colleagues, with an educational grant from
Pfizer Inc. No permission required to reproduce, translate, display or distribute.
