Date* MM slash DD slash YYYY Client name* First Last Date of Birth* MM slash DD slash YYYY PHQ-9 Modified for TeensInstruction: How often have you been bothered by each of the following symptoms during the past two weeks? 1. Feeling down, depressed, irritable, or hopeless?* Not at All Several Days More than half the days Nearly Every Day 2. Little interest or pleasure in doing things?* Not At All Several Days More Than Half the Days Nearly Every Day 3. Trouble falling asleep, staying asleep, or sleeping too much?* Not At All Several Days More Than Half the Days Nearly Every Day 4. Poor appetite, weight loss, or overeating?* Not At All Several Days More Than Half the Days Nearly Every Day 5. Feeling tired, or having little energy?* Not At All Several Days More Than Half the Days Nearly Every Day 6. Feeling bad about yourself — or feeling that you are a failure, or that you 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 like school work, reading, or watching TV?* 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 were 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 10. In the past year have you felt depressed or sad most days, even if you felt okay sometimes?* Yes No 11. If you are experiencing any of the problems on this form, 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 12. Has there been a time in the past month when you have had serious thoughts about ending your life?* Yes No 13. Have you ever, in your whole life, tried to kill yourself or made a suicide attempt?* Yes No PHQ-9 Teen ScoreAutomatically calculated - do not editUsed with Permission of the GLAD-PC Steering Group: www.GLAD-PC.org Source: Patient Health Questionnaire Modified for Teens (PHQ-9) (Author: Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues)
