Patient Health Questionnaire - Parkgate Medical Centre

Date of BirthDD/MM/YYYY

Over the last 2 weeks, how often have you had little interest or pleasure in doing things

Not at all

Several Days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you felt down, depressed, or hopeless

Not at all

Several Days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you had trouble falling/staying asleep, sleeping too much

Not at all

Several Days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you been feeling tired or having little energy

Not at all

Several Days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you had poor appetite or been overeating

Not at all

Several Days

More than half the days

Nearly every day

Over the last 2 weeks, how often have you been feeling bad about yourself or that 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

Over the last 2 weeks, how often have you 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

Over the last 2 weeks, how often have you experienced 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

Over the last 2 weeks, how often have you 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

I consent to my information being used for the purposes described above and wish to submit this online form to Parkgate Medical Centre • Netherfield Lane, Parkgate, Rotherham, S62 6AW.

Patient Health Questionnaire (PHQ-9)

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