PHQ9 - Woodinville Pediatrics

Your Name and relationship to patient *

Telehealth Appointment Provider *

Patient Name *

First

Last

Date of Birth *

Email *

1. Little interest or pleasure in doing things (that normally are interesting or pleasurable) *

Not at all
Several days
More than half the days
Nearly every day

2. Feeling down, depressed, or hopeless *

Not at all
Several days
More than half the days
Nearly every day

3. Trouble falling or staying asleep, or sleeping too much *

Not at all
Several days
More than half the days
Nearly every day

4. Feeling tired or having little energy *

Not at all
Several days
More than half the days
Nearly every day

5. Poor appetite or overeating *

Not at all
Several days
More than half the days
Nearly every day

6. 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

7. 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

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
Several days
More than half the days
Nearly every day

9. 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

Are you seeing a counselor/psychologist/psychiatrist?

Yes
No

If yes, the name of the counselor/psychologist/psychiatrist?

Additional comments or message