Patient Health Questionnaire (PHQ-9)

This form is not to be used for any emergency health problems. It is for review purposes only.

If you have been advised by the surgery to submit a Patient Health Questionnaire (PHQ-9) please use this form.

Patient Health Questionnaire (PHQ-9)

Patient Health Questionnaire (PHQ-9)

Review

Over the last 2 weeks, how often have you been bothered by any of the following problems:

Little interest or pleasure in doing things: *
Feeling down, depressed, or hopeless: *
Trouble falling or staying asleep, or sleeping too much: *
Feeling tired or having little energy: *
Poor appetite or overeating: *
Feeling bad about yourself — or that you are a failure or have let yourself or your family down: *
Trouble concentrating on things, such as reading the newspaper or watching television: *
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 usual: *
Thoughts that you would be better off dead or of hurting yourself in some way: *
Please answer the following questions using the following scale: 0 - never avoid it, 2- slightly avoid it, 4 - definitely avoid it, 6 - markedly avoid it, 8 - always avoid it
Social situations due to a fear of being embarrassed or making a fool of myself *
Certain situations because of a fear of having a panic attack or other distressing symptoms (such as loss of bladder control, vomiting or dizziness) *
Certain situations because of a fear of particular objects or activities (such as animals, heights, seeing blood, being in confined spaces, driving or flying) *
*