PHQ-9 Patient Questionnaire (Please print this out and take completed form to first appointment)
Patient Name: _______________________________________ Date: ________
This form is used as both a screening tool and a diagnostic tool for depression. Elaine Krantz, M.S., L.P.C. will discuss the form with you during your visit. Thank you for your cooperation and the opportunity to care for you.
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Not Several More than Nearly
at all days half the days every day
a. Little interest or pleasure in doing things
b. Feeling down, depressed, or hopeless.
c. Trouble falling/staying asleep, sleeping too much.
d. Feeling tired or having little energy.
e. Poor appetite or overeating.
f. Feeling bad about yourself – or that you are a failure or have let yourself or your family down.
g. Trouble concentrating on things, such as reading the newspaper or watching television.
h. 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.
i. Thoughts that you would be better off dead or of hurting yourself in some way.
If you 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
Copyright © Pfizer, Inc. All rights reserved. Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues, with an
educational grant from Pfizer, Inc. Adapted with permission from copyrighted material from Pfizer, Inc.