Index to Questionnaire – Health\Encounter – PHQ
UWH301924-DT (Rev. 01/22/18) PHQ-9 MODIFIED FOR ADOLESCENTS (PHQ-A)
(University of Wisconsin Hospitals and Clinics Authority)
PHQ-9 MODIFIED FOR ADOLESCENTS
Date: _________________________________ Clinician: _________________________________
Instructions: How often have you been bothered by each of the following symptoms during the past two
weeks? For each symptom put an “X” in the box beneath the answer that best describes how you have been feeling.
1. Feeling down, depressed, irritable, or hopeless?
2. Little interest or pleasure in doing things?
3. Trouble falling asleep, staying asleep, or sleeping too
4. Poor appetite, weight loss, or overeating?
5. Feeling tired, or having little energy?
6. Feeling bad about yourself – or feeling that you are a
failure, or that you have let yourself or your family
7. Trouble concentrating on things like school work,
reading or watching TV?
8. Moving or speaking so slowly that other people could
Or the opposite – being so fidgety or restless that you
were moving around a lot more than usual?
9. Thoughts that you would be better off dead, or of
hurting yourself in some way?
In the past year have you felt depressed or sad most days, even if you felt okay sometimes?
If you are experiencing any of the problems on this form, 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
Has there been a time in the past month when you have had serious thoughts about ending your life?
Have you EVER, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?
**If you have had thoughts that you would be better off dead or of hurting yourself in some way, please discuss
this with your Health Care Clinician, go to a hospital emergency room or call 911.
Office use only: Severity score: ______________
Modified with permission from the PHQ (Spitzer, Williams & Kroenke, 1999) by J. Johnson (Johnson, 2002)
Signature of Patient/Representative: ____________________________________ Date: __________ Time: ____________
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: ___________