PHQ-9 FORM

PointCare Medical Center

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PHQ-9 Form

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Patient / Client Name *

First

Last

Clinical Name

Date

Date of Birth

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

1. Little interest or pleasure in doing things

0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day

2. Feeling down, depressed or hopeless

0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day

3. Trouble falling or staying asleep, or sleeping too much

0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day

4. Feeling tired or having little energy

0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day

5. Poor appetite or overreacting

0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day

6. Feeling 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 day

7. Trouble 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 day

8. Moving or speaking so slowly that other people could

0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day

things, as 8.

9. Thoughts that you would be better off dead, or of hurting yourself

0 - Not at all
1 - Several days
2 - More than half the days
3 - Nearly every day

Score

Patient / Client Name *

First

Last

Patient/Client Signature

Clear Signature

We are committed to providing exceptional patient care and promoting wellness in our community here in the Twin Cities.

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Contact Details

1433 E Franklin Ave Suite 10 Minneapolis, MN 55404
[email protected]
9 AM - 6 PM , Monday - Friday
612-208-0985

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