Patient Health Questionnaire (PHQ-9)
Name
*
First Name
Last Name
Email
example@example.com
Select Your Therapist
*
Please Select
Bailey Belknap
Ingrid Benyaminowich
Leah Berdysz
Hannah Bickers
Megan Campagna
Eric Clontz
Aida Diallo
Jenny Eller
Scott Fralick
Jessica Glover
Lauren Greenberg
Melissa Grooms
Elizabeth Gunther
Pamela Hirt
Kelsey Hoisington
Jessica Jung
Nellimaria LaValle
Liz Mannon
Caitlin Martin
Sara Matlack
Christal Mendenhall
Gina Menninger
Katherine Mullin
Marshall L. Myers
Sara Napp
Anne Price
Jordan Redman
Amber Riley
Jodi Robertson
Hillary Schmidt
Jenifer Sparks-Schaffner
Linda Strapp
Kiera Tigner
MK Wright
1. Over the
last 2 weeks
, how often have you been bothered by any of the following problems?
a. Little interest or pleasure in doing things
Please Select
Not at all
Several days
More than half of the days
Nearly every day
b. Feeling down, depressed, or hopeless
Please Select
Not at all
Several days
More than half of the days
Nearly every day
c. Trouble falling/staying asleep, sleeping too much
Please Select
Not at all
Several days
More than half of the days
Nearly every day
d. Feeling tired or having little energy
Please Select
Not at all
Several days
More than half of the days
Nearly every day
e. Poor appetite or overeating
Please Select
Not at all
Several days
More than half of the days
Nearly every day
f. Feeling bad about yourself or that you are a failure, or have let yourself or your family down
Please Select
Not at all
Several days
More than half of the days
Nearly every day
g. Trouble concentrating on things, such as reading the newspaper or watching television.
Please Select
Not at all
Several days
More than half of the days
Nearly every day
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.
Please Select
Not at all
Several days
More than half of the days
Nearly every day
2. If you checked off any problem in 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?
Please Select
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Submit
Date of Birth
*
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Month
-
Day
Year
Date
Phone Number
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