Date * MM DD YYYY Date of Birth * Name * First Name Last Name Phone Country (###) ### #### Physician Name * Over the last two weeks, how often have you been bothered by any of the following problems? PHQ-9 * 1. Little interest or pleasure in doing things? 0 | Not at all. 1 | Several days. 2 | More than half the days. 3 | Nearly every day. 2. Feeling down, depressed, or hopeless. * 0 | Not at all. 1 | Several days. 2 | More than half the days. 3 | Nearly every day. 3. Trouble falling or staying asleep, or sleeping too much. * 0 | Not at all. 1 | Several days. 2 | More than half the days. 3 | Nearly every day. 4. Feeling tired or having little energy. * 0 | Not at all. 1 | Several days. 2 | More than half the days. 3 | Nearly every day. 5. Poor appetite or overeating. * 0 | Not at all. 1 | Several days. 2 | More than half the days. 3 | Nearly every day. 6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down. * 0 | Not at all. 1 | Several days. 2 | More than half the days. 3 | Nearly every day. 7. Trouble concentrating on things, such as reading the newspaper or watching television. * 0 | Not at all. 1 | Several days. 2 | More than half the days. 3 | Nearly every day. 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. * 0 | Not at all. 1 | Several days. 2 | More than half the days. 3 | Nearly every day. 9. Thoughts that you would be better off dead, or of hurting yourself in some way. * 0 | Not at all. 1 | Several days. 2 | More than half the days. 3 | Nearly every day. 10. 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? (Check one) * Not difficult at all Somewhat difficult Very Difficult Extremely Difficult Over the last 2 weeks, how often have you been bothered by any of the following problems? Please check one of each. GAD-7 1. Feeling nervous, anxious, or on edge. * 0 | Not at all sure. 1 | Several days. 2 | Over half the days 3 | Nearly every day 2. Not being able to stop or control worrying. * 0 | Not at all sure. 1 | Several days. 2 | Over half the days. 3 | Nearly every day. 3. Worrying too much about different things. * 0 | Not at all sure. 1 | Several days. 2 | Over half the days. 3 | Nearly every day. 4. Trouble relaxing. * 0 | Not at all sure. 1 | Several days. 2 | Over half the days. 3 | Nearly every day. 5. Being so restless that it’s hard to sit still. * 0 | Not at all sure. 1 | Several days. 2 | Over half the days. 3 | Nearly every day. 6. Becoming easily annoyed or irritable. * 0 | Not at all sure. 1 | Several days. 2 | Over half the days. 3 | Nearly every day. 7. Feeling afraid as if something awful might happen. * 0 | Not at all sure. 1 | Several days. 2 | Over half the days. 3 | Nearly every day. 8. 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? (check one) * Not difficult at all Somewhat difficult Very Difficult Extremely Difficult Thank you! Patient Health Questionnaire and General Anxiety Disorder (PHQ-9 and GAD-7)
