Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920HiddenEmail Patient Health Questionnaire PHQ-AOver the last 2 weeks, how often have you been bothered by any of the following problems? Read each item carefully and mark your response.Feeling down, depressed, or hopeless* Not at all Several days More than half the days Nearly every day Little interest or pleasure in doing things* 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 Poor appetite or over eating* 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 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 Thinking that you would be better off dead or that you want to hurt yourself in some way* Not at all Several days More than half the days Nearly every day In the past year have you felt depressed or sad most days, even if you felt okay sometimes?* Yes No 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 Has there been a time in the past month when you have had serious thoughts about ending your life?* Yes No Have you EVER, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?* Yes No
