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Patient Health Questionnaire-9 (PHQ-9) (301802-DT)

Patient Health Questionnaire-9 (PHQ-9) (301802-DT) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires



Patient Name

DOB:

MR #

Index to Questionnaire-Health\Encounter
UWH# 301802-DT (Rev. 06/10/16) PATIENT HEALTH QUESTIONNAIRE (PHQ-9)
UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
PATIENT HEALTH QUESTIONNAIRE
(PHQ-9)





Date:_______________________

Over the last 2 weeks, how often have you been bothered by any of the following problems?
Not at all Several
days
More than
half the
days
Nearly
everyday
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 or 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
0 + + +

=Total Score:__________

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 at all _____ Somewhat Difficult ______ Very Difficult______ Extremely Difficult______











Interpretation of Total Score: 1-4 Minimal Depression, 5-9 Mild Depression, 10-14 Moderate Depression, 15-19 Moderately Severe Depression, 20-27
Severe Depression
Developed by Drs. Robert Spitzer, Janet B.W. Williams, Kurt Kroenke and collegues, with an educational grant from Pfizer Inc. No permission required to
reproduce, translate, display or distribute.


Signature of Patient/Representative _________________________________Date: __________ Time: __________AM/PM


If signed by person other than the patient, print name and state relationship and authority to do so.

Print Name: _____________________________________Relationship: __________________________________

Patient is:  Minor  Incompetent / Incapacitated
Legal Authority:  Legal Guardian  Parent of Minor  Health Care Agent  Other _____________________

Reviewed by: ___________________________________________________ Date: ______________ Time: __________ AM/PM