Skip to content
Admin: PHQ
Michael
2023-02-22T09:15:20-06:00
PERSONAL HEALTH QUESTIONNAIRE
Patient Name
First
Last
This field is hidden when viewing the form
SCORE
My appointment is scheduled with:
Dr. Adamski
Dr. Linck
Anna Maria
Sarah
Dr. Damien
Tori
During the past two weeks...
1. I've had little interest or pleasure in doing things.
Not at all
Several days
More than half the days
Nearly every day
2. I've been feeling down, depressed or hopeless.
Not at all
Several days
More than half the days
Nearly every day
3. I've had trouble falling or staying asleep or sleeping too much.
Not at all
Several days
More than half the days
Nearly every day
4. I've been feeling tired or having little energy.
Not at all
Several days
More than half the days
Nearly every day
5. I've had a poor appetite or overeating.
Not at all
Several days
More than half the days
Nearly every day
6. You've been feeling bad about yourself - or that you are a failure or you have let yourself or your family down.
Not at all
Several days
More than half the days
Nearly every day
7. I've had 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
8. I've been 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
9. If you selected 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
10. You've had 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
11. In the past few weeks, have you wished you were dead?
Yes
No
12. In the past few weeks, have you felt that you or your family would be better off if you were dead?
Yes
No
13. In the past few weeks, have you been having thoughts about killing yourself.
Yes
No
14. Have you ever tried to kill yourself?
Yes
No
14a. How?
14b. When?
15. Are you having thoughts of killing yourself right now?
Yes
No
Page load link
