Park Leys Medical Practice

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PHQ9

You may have been asked by a doctor to complete a PHQ9 form. This is a tool used by doctors to assess levels of depression.

Please do not submit a form unless you have been requested to do so by a GP.

If you would prefer to do so you can download a copy of the form and bring it into the practice or post it to us.

Over the last 2 weeks, how often have you been bothered by any of the following problems? Please select from the answers provided.

Your Name?*:

Your Date of Birth?*:

Your email address?*:

Requested by Dr?*:

1. Little Interest or Pleasure in doing things*:

2. Feeling down, depressed or hopeless*:

3. Having trouble falling, or staying asleep, or sleeping to 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*:

10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?*:

Enter the letters showed into the following image*:

Conditions of Processing :

This message is processed on the basis that the patient consents for this information to be transmitted by email and accepts that confidentiality cannot be guaranteed.

I agree I do not agree

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