Pondworks Psychiatry & Psychotherapy

The Patient Health Questionnaire (PHQ-9)

Patient initials * Provider name * Date of appointment *

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

1. Little interest or pleasure in doing things * 2. Feeling down, depressed or hopeless * 3. Trouble falling asleep, staying asleep, or sleeping too much * 4. Feeling tired or having little energy * 5. Poor appetite or overeating * 6. Feeling bad about yourself - or that you're a failure or have let yourself or your family down * 7. Trouble concentrating on things, such as reading the newspaper or watching television * 8. 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 * 9. Thoughts that you would be better off dead or of hurting yourself in some way * 10. 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? *

To Be Completed By Pondworks Staff

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