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Depression Screening (PHQ-9)
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Name
*
First
Last
Email
*
Phone
or Results down,
Date of Birth:
Over the last 2 weeks, how often have you been bothered by the following problems?
Little interest or pleasure in doing things
*
Select One
Not at all
Several days
More than half the days
Nearly every day
Feeling down, depressed, or hopeless
*
Select One
Not at all
Several days
More than half the days
Nearly every day
Trouble falling asleep, staying asleep, or sleeping too much
*
Select One
Not at all
Several days
More than half the days
Nearly every day
Feeling tired or having little energy
*
Select One
Not at all
Several days
More than half the days
Nearly every day
Poor appetite or overeating
*
Select One
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
*
Select One
Not at all
Several days
More than half the days
Nearly every day
Trouble concentrating on things, such as reading or watching television
*
Select One
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 fidgety or restless
*
Select One
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
*
Select One
Not at all
Several days
More than half the days
Nearly every day
Results
Results
Results of the assessment 1
Mild Depression
Results of the assessment 2
Moderate Depression
Results of the assessment 3
Severe Depression
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