Screening Instrument for Depression (PHQ-9) Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Patient's Name *FirstMiddleLastPatient's Date of Birth: *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Over the past two weeks, how often have you been bothered by any of the following problems? Little interest pr pleasure in doing things *(0) Not at all(1) Several days(2) More than half the days(3) Nearly every dayFeeling down, depressed, or hopeless *(0) Not at all(1) Several days(2) More than half the days(3) Nearly every dayTrouble falling or staying asleep, or sleeping too much *(0) Not at all(1) Several days(2) More than half the days(3) Nearly every dayFeeling tired or having little energy *(0) Not at all(1) Several days(2) More than half the days(3) Nearly every dayPoor appetite or overeating *(0) Not at all(1) Several days(2) More than half the days(3) Nearly every dayFeeling bad about yourself or that you are a failure or have let yourself or your family down *(0) Not at all(1) Several days(2) More than half the days(3) Nearly every dayTrouble concentrating on things, such as reading the newspaper or watching television *(0) Not at all(1) Several days(2) More than half the days(3) Nearly every dayMoving 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 *(0) Not at all(1) Several days(2) More than half the days(3) Nearly every dayThoughts that you would be better off dead or of hurting yourself in some way *(0) Not at all(1) Several days(2) More than half the days(3) Nearly every dayScoring How many times did you choose "Not at all" ? TOTAL:: 0 How many times did you choose "Several days" ? TOTAL:: 0 How many times did you choose "More than half the days" ? TOTAL:: 0 How many times did you choose "Nearly every day" ? TOTAL:: 0 Overall Score: *Add the previous four totals together to get your overall scoreTotal0-4 = minimal depression5-9 = mild depression10-14 = moderate depression15 to 19 = moderately severe depression20-27 = severe depression If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? *Not at allSomewhat difficultVery difficultExtremely Difficult PHQ = Patient Health Questionnaire. Adapted from Patient Health Questionnaire (PHQ) screeners (http://www:phqscreeners.com). Accessed February 8, 2018. Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. Patient or Parent/Guardian Electronic SignatureIf the patient is under 18 years of age, a parent or legal guardian is required to agree and sign the electronic formToday's DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Patient or Parent/Guardian Date of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920AGREE YES, I AGREE By selecting the “I AGREE” button, I am signing this document electronically. I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting “I agree” using any device, means, or action, I consent to the legally binding terms and conditions of this document. I further agree that my signature on this document is as valid as if I signed the document in writing. I am also confirming that I am authorized to enter into this Agreement. If I am signing this document on behalf of a minor, I represent and warrant that I am the minor’s parent or legal guardian. I may decline to electronically sign this document and withdraw my consent to sign this document electronically by contacting the signature requestor directly, which may delay transactions. I may contact the signature requestor separately to request to sign this document on paper or to receive a paper copy of the signed document. Any fees for such paper copy will be charged then by the signature requestor. When I sign the document, I will receive a copy of this document via email. Submit
