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? *

About Us

The Geriatric Psychiatry Outpatient Services provide comprehensive services for adults ages 65 and older with depression, anxiety, and cognitive function disorders. Our array of outpatient programs offer individual and group therapy, incorporating diagnostic evaluation.

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