Patient Health Questionnaire

Please add the numbers to your answers and match with chart.
0 – 4 None

5 – 9. Consider Evaluation

10 – 14. Considering counseling or pharmacotherapy

15 – 19. Severe Active treatment with pharmacotherapy

20 – 27. Severe Immediate initiation of pharmacotherapy and, expedited referral to a mental health specialist for psychotherapy and/or medication management

Take 5 minute free assessment

First name*

Last name*

Email*

Phone*

little interest in pleasure or doing things?*

Not at all - 0

several days +1

more than half the days +2

nearly every day +3

Feeling down depressed or hopeless?*

Not at all - 0

several days +1

more than half the days +2

nearly every day +3

Trouble falling asleep, staying asleep, or sleeping too much*

Not at all - 0

several days +1

more than half the days +2

nearly every day +3

Feeling tired or having little energy*

Not at all - 0

several days +1

more than half the days +2

nearly every day +3

Poor appetite or overeating*

Not at all - 0

several days +1

more than half the days +2

nearly every day +3

Feeling bad about yourself - or that you’re a failure or have let yourself or your family down*

Not at all - 0

several days +1

more than half the days +2

nearly every day +3

Trouble concentrating on things, such as reading the newspaper or watching television*

Not at all - 0

several days +1

more than half the days +2

nearly every day +3

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 - 0

several days +1

more than half the days +2

nearly every day +3

Thoughts that you would be better off dead or of hurting yourself in some way*

Not at all - 0

several days +1

more than half the days +2

nearly every day +3