Depression Assessment Tool PHQ-9 Client Name* First Last Birthdate* MM slash DD slash YYYY Are you experiencing symptoms of depression?* Yes No PHQ-9 Depression Assessment toolOver the past 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 all1. Several days2-More than half the days3-Nearly every day2. Feeling down, depressed or hopelelss.0-Not at all1. Several days2-More than half the days3-Nearly every day3-Trouble falling asleep, staying asleep, or sleeping too much.0-Not at all1. Several days2-More than half the days3-Nearly every day4-Feeling tired or having little energy0-Not at all1. Several days2-More than half the days3-Nearly every day5-Poor appetitie or over eating0-Not at all1. Several days2-More than half the days3-Nearly every day6-Feeling bad about yourself-or that you're a failure or have let yourself or your family down0-Not at all1. Several days2-More than half the days3-Nearly every day7-Trouble concentrating on things, such as reading the newspaper or watching television0-Not at all1. Several days2-More than half the days3-Nearly every day8-Moving or speaking so slowly that other people could have noticed. Or the opposite-being so figity or restless that you have been moving around a lot more than usual.0-Not at all1. Several days2-More than half the days3-Nearly every day9-Thoughts that you would be better off dead or hurting yourself in some way.0-Not at all1. Several days2-More than half the days3-Nearly every dayIf 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 allSomewhat difficultVery difficultExtremely difficultTotal ScoreScoring your depression on the PHQ-9 assessment toolSelect your score range hereA score of 0 is rated as no depressionA score of 1-4 is rated as a minimal depressionA score of 5-9 is rated as a mild depressionA score of 10-14 is rated as a moderate depressionA score of 15-19 is rated as a moderately severe depressionA score of 20-27 is rated as a severe depressionName of the person who provided the information for this assessment.* First Last Enter the email address given to you by your provider. Submission ID
