This form is only to be filled out by existing patients. Thank you. Patient Intake Form: PHQ9 Form "*" indicates required fields Patient Health Questionaire - 9Date* MM slash DD slash YYYY First Name* Last Name* Phone* Email* Date of Birth* 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 of 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 tat 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 concetrating 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 someway* Not at All Several Days More than half the days Nearly Every Day In ClosingIf 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
