Initial of Patient Last Name: _____________ Last 4 digits of SSN: ___________________
Therapist Initials: ______________________ Date: ____________ Session: ___________
B22
PHQ-9
Over the last 2 weeks, how often have you been bothered by any
of the following problems?
R
ead each item carefully, and circle your response.
at all
days
than half
the days
every day
1. Little interest or pleasure in doing things
0 1 2 3
2. Feeling down, depressed, or hopeless
0 1 2 3
3. Trouble falling asleep, staying asleep, or sleeping too much
0 1 2 3
4. Feeling tired or having little energy
0 1 2 3
5. Poor appetite or overeating
0 1 2 3
6. Feeling bad about yourself — or that you are a failure or have let
yourself or your family down
0 1 2 3
7. Trouble concentrating on things, such as reading the newspaper or
watching television
0 1 2 3
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
0 1 2 3
9. Thoughts that you would be better off dead or of hurting yourself in
some way
0 1 2 3
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?
at all
�
difficult
�
difficult
�
Difficult
�
PHQ-9: 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.
