PHQ-9 and GAD-7

Please complete the form below, and submit it to your provider before your scheduled appointment.

Patient Health Questionnaire and General Anxiety Disorder (PHQ-9 and GAD-7)

Date(Required)

Patient Name(Required)

Date of Birth(Required)

PHQ-9

Over the last two weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things.

2. Feeling down, depressed, or hopeless.

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

4. Feeling tired or having little energy.

5. Poor appetite or overeating.

6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down.

7. Trouble concentrating on things, such as reading the newspaper or watching television.

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.

9. Thoughts that you would be better off dead, or of hurting yourself in some way.

Total Score (add your column scores):

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? (Circle one)(Required)

Not difficult at all

Somewhat difficult

Very Difficult

Extremely Difficult

GAD-7

Over the last two weeks, how often have you been bothered by any of the following problems?

1. Feeling nervous, anxious, or on edge.

2. Not being able to stop or control worrying

3. Worrying too much about different things.

4. Trouble relaxing

5. Being so restless that it’s hard to sit still.

6. Becoming easily annoyed or irritable.

7. Feeling afraid as if something awful might happen.