Patient Health Questionaire 

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Little interest or pleasure 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 trouble 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 normal *

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 in some way *

Not at all

Several days

More than half the days

Nearly every day

If you checked any of the 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