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Patient Health Questionnaire

PATIENT NAME
DATE

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
  Not at all
  
  Several days
  
  More than half the days
  
  Nearly every day
2. Feeling down, depressed, or hopeless
  Not at all
  
  Several days
  
  More than half the days
  
  Nearly every day
3. Trouble falling/staying asleep, sleeping too much
  Not at all
  
  Several days
  
  More than half the days
  
  Nearly every day
4. Feeling tired or having little energy
  Not at all
  
  Several days
  
  More than half the days
  
  Nearly every day
5. Poor appetite or overeating
  Not at all
  
  Several days
  
  More than half the days
  
  Nearly every day
6. Feeling bad about yourself or that you are a failure or have let yourself or your family down
  Not at all
  
  Several days
  
  More than half the days
  
  Nearly every day
7. Trouble concentrating on things, such as reading the newspaper or watching television
  Not at all
  
  Several days
  
  More than half the days
  
  Nearly every day
8. 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
  Not at all
  
  Several days
  
  More than half the days
  
  Nearly every day
9. Thoughts that you would be better off dead or of hurting yourself in some way
  Not at all
  
  Several days
  
  More than half the days
  
  Nearly every day
If you have checked off any problem on this questionnaire so far, 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 all

Somewhat difficult

Very difficult

Extremely difficult

Leave this empty:

Your legal name

Your email address

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Timestamp

Audit

June 18, 2022 9:15 am CST

Patient Health Questionnaire Uploaded by BMH Front Desk - jlowery@modintelechy.com IP 66.68.60.75