NAME:   _________________________			DATE:  ___________________

DATE OF BIRTH: __________________ 	

Depression Health Questionnaire PHQ-9

Over the last 2 weeks, how often have you been
bothered by any of the following problems?
(Use ‘√’ to indicate your answer)

	
Not at all	
Several days	
More than half the days	
Nearly every day	

1.Little interest or pleasure in doing things

2. Feeling down, depressed or hopeless

3. Trouble falling or staying  asleep or sleeping too much

4. Feeling tired or having little energy

5. Poor appetite or overeating

6. Feeling bad about yourself – or that you are a failure or have let  yourself
or family down

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

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

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

                                                                       Add columns     TOTAL

(Healthcare professional: For interpretation of TOTAL,
please refer to accompanying scoring card).

10. If you checked off any problems, how difficult have these                                      Not difficult at all       
problems made it for you to do your work, take care of things                                     Somewhat difficult     
at home or get along with other people?                                                                          Very difficult              
                                                                                                                                              Extremely difficult