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

    Date of Birth
    For example, 15 3 1984

  • 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
    Feeling down, depressed, or hopeless
    Trouble falling or staying asleep, or sleeping too much
    Feeling tired or having little energy
    Poor appetite or overeating
    Feeling bad about yourself — or that you are a failure or have let yourself or your family down
    Trouble concentrating on things, such as reading the newspaper or watching television
    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
    Thoughts that you would be better off dead or of hurting yourself in some way
    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?

  • 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

    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.
This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
Page last reviewed: 22 February 2023
Page created: 27 July 2022