PHQ-9/GAD-7

Chief Complaint

Patient Health and Anxiety Questionnaire Form

Form Content

Introduction: I will help you complete the PHQ9 and GAD-7 questionnaires. The information that you provide will be summarized for your physician and discussed in your visit. We estimate this questionnaire will take around 15 minutes to complete. If you must stop, you can return at a later time to finish. If you want me to repeat a question, just say "repeat." Are you ready? PHQ-9 (Patient Health Questionnaire): 1. Over the last 2 weeks, how often have you been bothered by any of the following problems? Please rate each from 0 (Not at all) to 3 (Nearly every day): - Little interest or pleasure in doing things - Feeling down, depressed, or hopeless - Trouble falling or staying asleep, or sleeping too much - Feeling tired or having little energy - Poor appetite or overeating - Feeling bad about yourself – or that you are a failure or have let yourself or your family down - Trouble concentrating on things, such as reading the newspaper or watching television - Moving or speaking so slowly that other people could have noticed, or being so fidgety or restless that you have been moving around a lot more than usual - Thoughts that you would be better off dead, or of hurting yourself in some way 2. If you checked off any problems, how difficult have these 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 - Extremely Difficult GAD-7 (General Anxiety Disorder): 3. Over the last 2 weeks, how often have you been bothered by any of the following problems? Please rate each from 0 (Not at all sure) to 3 (Nearly every day): - Feeling nervous, anxious, or on edge - Not being able to stop or control worrying - Worrying too much about different things - Trouble relaxing - Being so restless that it’s hard to sit still - Becoming easily annoyed or irritable - Feeling afraid as if something awful might happen 4. If you checked off any problems, how difficult have these 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 - Extremely Difficult