Today's Date* MM slash DD slash YYYY Name* First Last Date of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920This field is hidden when viewing the formEmail Enter Email Confirm Email Patient Health Questionnaire PHQ-9Over the last 2 weeks, how often have you been bothered by any of the following problems? Read each item carefully and mark your response.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 asleep, 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 notice. Or the opposite - being so fidgety or restless that you are 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 in some way Not at all Several days More than half the days Nearly every day How difficult have these problems made it for you at work, home, or getting along with others? Not difficult at all Somewhat difficult Very difficult Extremely difficult
