Osteopathic Family Medicine, LLC

Available Forms

Alcohol Questionnaire Change of contact or insurance information Depression Screening Questionaire (PHQ-9) Eating Disorder Screening GAD-7 Medicare Health Risk Assessment Patient Satisfaction Survey - CAHPS/PCMH Version 3.0 Social Determinants of Health

Depression Screening Questionaire (PHQ-9)

Patient Name *

Type your name

Today's Date *

Pick Today's Date

Over the past 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things *

Feeling down, depressed, hopeless *

Trouble falling asleep, staying asleep, or sleeping too much *

Feeling tired or having little energy *

Poor appetite or overeating *

Feeling bad about yourself - or that you'r a failure or have let yourself or your family down *

Trouble concentrating on things such as reading the newspaper or watching television *

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. *

Thoughts that you would be better off dead or of hurting yourself in some way *

If you checked off any problems, how difficult have those problems made it for you to Do your work, take care of things at home, or get along with other people? *

* Required field