Patient Health Questionnaire-9 (PHQ-9)

Over the last 2 weeks, how often have you been bothered by any of the following problems? Fields marked * are required.

Patient Information

Patient First Name*

Patient Last Name*

Date of Birth*

Used to file this form with the correct patient record. (Not part of the original paper form.)

Date*

PHQ-9

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

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

Total Score (out of 27)

Severity

Standard PHQ-9 severity ranges: 0-4 Minimal | 5-9 Mild | 10-14 Moderate | 15-19 Moderately Severe | 20-27 Severe. (Not printed on the original form; added here using the standard, widely published PHQ-9 scoring bands.)

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 difficult at all Somewhat difficult Very difficult Extremely difficult

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.

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Thank you

Your questionnaire has been received.