PHQ9 Form - A Reiki Life Academy®

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Stress Management Consulting
Health Questionnaire: PHQ-9 Form

Health Questionnaire (9 questions)

Over the last 2 weeks, how often have you been bothered by any of the following problems?

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Little interest or pleasure in doing things *

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

Feeling down, depressed, or hopeless *

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

Trouble falling or staying asleep, or sleeping too much *

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

Feeling tired or having little energy *

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

Poor appetite or overeating *

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

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

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

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

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

If you checked off any problems in the above questions, 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? *

Not difficult at all Somewhat difficult Very difficult Extremely difficult

Submit

704-996-4079

© Copyright 2009 Nancy Bunt. All Rights Reserved.
A Reki Life Academy® is a division of A Reiki Life, LLC

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