PHQ-9

PHQ-9

Patient Health Questionnaire (PHQ-9)

Important Notice: The information gathered on this questionnaire will remain confidential.

First Name*

MI/Middle Initial

Last Name*

Email*

Date of Birth*

Date of Visit*

Over the last two weeks, how often have you been bothered by the following problems?

  1. Little interest or pleasure in doing things.
     0-Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day
  2. Feeling down, depressed or hopeless.
     0-Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day
  3. Trouble falling asleep or staying asleep or sleeping too much.
     0-Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day
  4. Feeling tired or having little energy.
     0-Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day
  5. Poor appetite or overeating.
     0-Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day
  6. Feeling bad about yourself, that you are a failure, you have let yourself or your family down.
     0-Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day
  7. Trouble concentrating on things, such as reading the newspaper or watching the TV.
     0-Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day
  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-Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day
  9. Thoughts that you would be better off dead or hurting yourself in some way.
     0-Not at all 1 - Several days 2 - More than half the days 3 - Nearly every day

Sunny Hills TMS

Phone:
714-888-8418

Address:
140 E. Commonwealth Ave.
Suite 101
Fullerton, CA 92832

 

Serving:

TMS Fullerton CA
TMS Anaheim CA
TMS South Los Angeles
TMS Yorba Linda CA
TMS Lakewood CA
TMS Santa Ana CA
TMS Brea CA
TMS Garden Grove CA
TMS City of Industry CA
TMS Downey CA
TMS Chino CA