Form 1 Attachment C: PHQ-9

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Attachment C: Patient Health Questionnaire (PHQ-9)

PATIENT HEAL TH QUESTIONNAIRE (PHQ-9)

NAME: ____________________

DATE�·--------

Over the last 2 weeks, how often have you been
bothered by any of the following problems?
(use"

✓

"

to indicate your answer)

Several
days

More than
half the
days

Nearly
every day

0

1

2

3

0

1

2

3

0

1

2

3

0

1

2

3

0

1

2

3

0

1

2

3

0

1

2

3

0

1

2

3

0

1

2

3

Not at all

1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself-or that you are a failure or

have let yourself or your family down
7. Trouble concentrating on things, such as reading the

newspaper or watching television
8. Moving or speaking so slowly that other people could

have noticed. Or the opposite - being so figety or
restless that you have been moving around a lot more
than usual
9. Thoughts that you would be better off dead, or of

hurting yourself

add columns
(Healthcare professional: For interpretation of TOTAL,
please refer to accompanying scoring card).
10. 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?

+

+

TOTAL:
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult

Copyright© 1999 Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD© is a trademark of Pfizer Inc.
A2663B 10-04-2005

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is
protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C.
242m(d)]. Information that could identify you will not be disclosed unless you have consented to that
disclosure. Public reporting burden for this collection of information is estimated to average 3 minutes per
response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless it displays a currently valid OMB
control number. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention:
PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD
20857.