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Patient Health Questionnaire - Depression Screening
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Patient Health Questionnaire - Depression Screening
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things
*
Not at all
Several days
More than half the days
Nearly every day
Feeling down, depressed, or hopeless
*
Not at all
Several days
More than half the days
Nearly every day
Trouble falling or staying asleep, or sleeping too much
*
Not at all
Several days
More than half the days
Nearly every day
Feeling tired or having little energy
*
Not at all
Several days
More than half the days
Nearly every day
Poor appetite or overeating
*
Not at all
Several days
More than half the days
Nearly every day
Feeling bad about yourself, or that you are a failure or have let yourself or your family down
*
Not at all
Several days
More than half the days
Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television
*
Not at all
Several days
More than half the days
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
*
Not at all
Several days
More than half the days
Nearly every day
Thoughts that you would be better off dead, or of hurting yourself
*
Not at all
Several days
More than half the days
Nearly every day
If you have 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
NAME
*
NAME
DATE OF BIRTH
*
DATE OF BIRTH
PHONE #
*
PHONE NUMBER
* Required field
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