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PHQ-9

Crossroads Behavioral Health Services
210 Russell Street
Phone 641-782-8457
Fax 641-782-7048
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
Over the last 2 weeks, how often have you been bothered by any of 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, 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 - or that you are a failure or 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 television
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 of hurting yourself in some way
0 - Not at all   1 - Several days   2 - More than half the days  
3 - Nearly every day     
Total Score:
* Please enter score from above:
PSS-3
Over the past 2 weeks, have you had thoughts of killing yourself?
Yes   No   Refused  
Patient unable to complete     
Have you ever attempted to kill yourself?
Yes   No   Refused  
Patient unable to complete     
If yes to the last question, when did this happen?
Within the past 24 hours (including today)   Within the last month (but not today)   Between 1 and 6 months ago  
More than 6 months ago   Refused   Patient unable to complete  
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