Patient Health Questionnaire
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Full Name *
Phone Number *
INSTRUCTIONS: This scale is designed for your personal use. There are no right or wrong answers. Usually your first response is the best. Please print these pages out for your personal use. You may also bring this assessment with you to your appointment and discuss the findings during your visit.
Little interest or pleasure in doing things
Clear selection
Feeling down, depressed, or hopeless
Clear selection
Feeling down, depressed, or hopeless
Clear selection
Trouble falling or staying asleep, or sleeping too much
Clear selection
Feeling tired or having little energy
Clear selection
Poor appetite or overeating
Clear selection
Feeling bad about yourself — or that you are a failure orhave let yourself or your family down
Clear selection
Trouble concentrating on things, such as reading thenewspaper or watching television
Clear selection
Moving or speaking so slowly that other people could havenoticed? Or the opposite — being so fidgety or restlessthat you have been moving around a lot more than usual
Clear selection
Thoughts that you would be better off dead or of hurtingyourself in some way
Clear selection
If you checked off any problems, how difficult have these problems made it for you to do yourwork, take care of things at home, or get along with other people?
Clear selection
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