Name: | ||||
Clinician: | Date: | |||
Instructions: How often have you been bothered by each of the following symptoms during the past two weeks? For each symptom put an "X" in the box beneath the answer that best describes how you have been feeling. | ||||
Not at all | Several days | More than half the days | Nearly every day | |
Score | (0) | (1) | (2) | (3) |
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Total ___ = | ___ | + ___ | + ___ | + ___ |
PHQ-9 score ≥10: Likely major depression | ||||
Depression score ranges: | ||||
0 to 4: No or minimal depression | ||||
5 to 9: Mild | ||||
10 to 14: Moderate | ||||
15 to 19: Moderately severe | ||||
≥20: Severe | ||||
In the past year have you felt depressed or sad most days, even if you felt okay sometimes? | ||||
Yes No | ||||
If you are experiencing any of the problems on this form, 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 | ||||
Has there been a time in the past month when you have had serious thoughts about ending your life? | ||||
Yes No | ||||
Have you ever, in your whole life, tried to kill yourself or made a suicide attempt? | ||||
Yes No | ||||
FOR OFFICE USE ONLY | Score: |
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