Screening Depression

Name of the patient *

Name of the referring Doctor

Contact Number of Patient / Referring Doctor *

Email Address

Date of Birth of Patient *

Gender, Marital Status & Career *0 / 500

1. Little Interest or Pleasure in doing things *Not At All in Past Two WeeksSeveral Days in Past Two WeeksMore Than Half the Days in Past Two WeeksNearly Every Day In The Past Two Weeks

2. Feeling Down, Depressed, Hopeless *Not At All in Past Two WeeksSeveral Days in Past Two WeeksMore Than Half the Days in Past Two WeeksNearly Every Day In The Past Two Weeks

3. Trouble falling or staying asleep Or sleeping too much *Not At All in Past Two WeeksSeveral Days in Past Two WeeksMore Than Half the Days in Past Two WeeksNearly Every Day In The Past Two Weeks

4. Feeling tired or having little energy *Not At All in Past Two WeeksSeveral Days in Past Two WeeksMore Than Half the Days in Past Two WeeksNearly Every Day In The Past Two Weeks

5. Poor appetite (desire to eat food) or overeating *Not At All in Past Two WeeksSeveral Days in Past Two WeeksMore Than Half the Days in Past Two WeeksNearly Every Day In The Past Two Weeks

6. Feeling bad about yourself - or that you are a failure or have let yourself / your family down *Not At All in Past Two WeeksSeveral Days in Past Two WeeksMore Than Half the Days in Past Two WeeksNearly Every Day In The Past Two Weeks

7. Trouble concentrating on things, such as reading the newspaper or watching television *Not At All in Past Two WeeksSeveral Days in Past Two WeeksMore Than Half the Days in Past Two WeeksNearly Every Day In The Past Two Weeks

8. 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 in Past Two WeeksSeveral Days in Past Two WeeksMore Than Half the Days in Past Two WeeksNearly Every Day In The Past Two Weeks

9. Thoughts that you would be better off dead or of hurting yourself in some way *Not At All in Past Two WeeksSeveral Days in Past Two WeeksMore Than Half the Days in Past Two WeeksNearly Every Day In The Past Two Weeks

10. Which of the above problems were NOT AT ALL MAKING DIFFICULT for doing your work, take care of things at home or get along with other people *

11. Which of the above problems were making SOMEWHAT DIFFICULT for doing your work, take care of things at home or get along with other people *

12. Which of the above problems were making VERY DIFFICULT for doing your work, take care of things at home or get along with other people *

13. Which of the above problems were making EXTREMELY DIFFICULT for doing your work, take care of things at home or get along with other people *

PHQ 9 - if Total Score is 5 or above MILD Depression; if 10 or above MODERATE Depression; if 15 or above MODERATELY SEVERE Depression and if 20 or above SEVERE Depression

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