Patient Health Assessment (PHQ-9) Home Patient Health Assessment (PHQ-9) Back to Home Patient Health Assessment (PHQ-9) Patient Health Assessment (PHQ-9) If you have been advised by the surgery to submit a Patient Health Questionnaire (PHQ-9) please use this form. Your Details Name Date of Birth For example, 15 3 1984 Day Month Year Phone Number (optional) Email Address Patient Health Review Over the last 2 weeks, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things Not at all Several days More than half the days Nearly every day Feeling down, depressed, or hopeless Not at all Several days More than half the days Nearly every day Trouble falling or staying asleep, or sleeping too much Not at all Several days More than half the days Nearly every day Feeling tired or having little energy Not at all Several days More than half the days Nearly every day Poor appetite or overeating Not at all Several days More than half the days Nearly every day 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 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 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 Not at all Several days More than half the days Nearly every day Thoughts that you would be better off dead or of hurting yourself in some way Not at all Several days More than half the days Nearly every day If you checked off any problems, 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 Rate by Scale Please answer the following questions using the following scale: 0 – never avoid it, 2- slightly avoid it, 4 – definitely avoid it, 6 – markedly avoid it, 8 – always avoid it Social situations due to a fear of being embarrassed or making a fool of myself Please select an answer 0 1 2 3 4 5 6 7 8 Certain Situations Because of a Fear of Having a Panic Attack or Other Distressing Symptoms (Such as Loss of Bladder Control, Vomiting or Dizziness) Please select an answer 0 1 2 3 4 5 6 7 8 Certain Situations Because of a Fear of Particular Objects or Activities (Such as Animals, Heights, Seeing Blood, Being in Confined Spaces, Driving or Flying) Please select an answer 0 1 2 3 4 5 6 7 8 This Form Collects Your Name, Date of Birth, Email, Other Personal Information and Medical Details. This is to Confirm You Are Registered With the Practice, to Allow the Practice Team to Contact You and Also to Update Your Medical Records Held by the Practice and Our Partners in the Nhs. Please Read Our Privacy Policy to Discover How We Protect and Manage Your Submitted Data. I consent to the practice collecting and storing my data from this form. Submit Form Oops… There was an error contacting reCAPTCHA, Please try again. This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Page last reviewed: 22 February 2023 Page created: 20 March 2023