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David Schechter, M.D.
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Patient Health Questionnaire - Depression Screening
FULL NAME
*
First Last
DATE
*
Today's date
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things
*
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Feeling down, depressed, or hopeless
*
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Trouble falling or staying asleep, or sleeping too much
*
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Feeling tired or having little energy
*
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Poor appetite or overeating
*
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Feeling bad about yourself, or that you are a failure or have let yourself or your family down
*
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television
*
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Moving 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 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Thoughts that you would be better off dead, or of hurting yourself
*
0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day
Add all numerical values for Total Score =
* Required field
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