Patient Health Assessment

Non-urgent advice: Please Note

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

Contact Details

Name
Date
Home Address

Questionnaire

Over the last two 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

Finally

Regarding the questions above, if you checked off “Several days”, “More than half the days” or “Nearly every day”; how
have these problems effected your ability to do your work, take care of things at home, or get along with other people?

The problems I've checked off above…