Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.CLIENT DETAILSDate *Client Name *FirstLastDate of Birth *Patient Health Questionnaire – 9 (PHQ – 9)Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 – Not at all 1 – Several Days 2 – More than half the days 3 – Nearly Every day Little interest or pleasure in doing things Selected Value: 0 Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 – Not at all 1 – Several Days 2 – More than half the days 3 – Nearly Every day Feeling down, depressed or hopeless Selected Value: 0 Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 – Not at all 1 – Several Days 2 – More than half the days 3 – Nearly Every day that Thoughts these Trouble falling or staying asleep, or sleeping too much Selected Value: 0 Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 – Not at all 1 – Several Days 2 – More than half the days 3 – Nearly Every day Feeling tired or having little energy Selected Value: 0 Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 – Not at all 1 – Several Days 2 – More than half the days 3 – Nearly Every day Poor appetite or overeating Selected Value: 0 Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 – Not at all 1 – Several Days 2 – More than half the days 3 – Nearly Every day Feeling bad about yourself – or that you are a failure or have let yourself or family down Selected Value: 0 Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 – Not at all 1 – Several Days 2 – More than half the days 3 – Nearly Every day Trouble concentrating on things, such as reading the newspaper or watching television Selected Value: 0 Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 – Not at all 1 – Several Days 2 – More than half the days 3 – Nearly Every day 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 Selected Value: 0 Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 – Not at all 1 – Several Days 2 – More than half the days 3 – Nearly Every day Thoughts that you would be better off dead or of hurting yourself in some way Selected Value: 0 Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 – Not at all 1 – Several Days 2 – More than half the days 3 – Nearly Every day If you checked off any problems above, 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 difficult at allSomewhat difficultVery DifficultExtremely DifficultSubmit
