Self-Assessment Health Questionnaire

The following Patient Health Questionnaire is a multipurpose self-assessment to assist your physician in screening, diagnosing, and measuring the severity of depression.

Patient Name *

First

Last

Email *

1. Little interest or pleasure in doing things *

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

2. Feeling down, depressed, or hopeless *

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

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

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

4. Feeling tired or having little energy *

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

5. Poor appetite or overeating *

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

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

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

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

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

8. Moving or speaking so slowly that other people could notice. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual *

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

9. Thoughts that you would be better off dead, or of hurting yourself *

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

Would you be interested in learning more about a safe, effective, non-drug treatment for depression? *

Yes
No