Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name* First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email 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 allSeveral daysMore than half the daysNearly every dayLittle interest or pleasure in doing things*Not at allSeveral daysMore than half the daysNearly every dayTrouble falling asleep, staying asleep, or sleeping too much*Not at allSeveral daysMore than half the daysNearly every dayPoor appetite or over eating*Not at allSeveral daysMore than half the daysNearly every dayFeeling tired or having little energy*Not at allSeveral daysMore than half the daysNearly every dayFeeling bad about yourself - or that you are a failure or have let yourself or your family down*Not at allSeveral daysMore than half the daysNearly every dayTrouble concentrating on things such as reading the newspaper or watching television*Not at allSeveral daysMore than half the daysNearly every dayMoving 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 allSeveral daysMore than half the daysNearly every dayThinking that you would be better off dead or that you want to hurt yourself in some way*Not at allSeveral daysMore than half the daysNearly every dayIn the past year have you felt depressed or sad most days, even if you felt okay sometimes?*YesNoHow difficult have these problems made it for you at work, home, or getting along with others?*Not difficult at allSomewhat difficultVery difficultExtremely difficultHas there been a time in the past month when you have had serious thoughts about ending your life?*YesNoHave you EVER, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?*YesNo
