Mental Health Assessment Form

Questions	Concepts
PHQ-2
Screening Date ␣␣-␣␣-␣␣␣␣ 📆	160753AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
Little interest or pleasure in doing things 🔘 Not at all 🔘 Several days 🔘 More than half the days 🔘 Nearly every day	167006AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
Feeling down, depressed or hopeless 🔘 Not at all 🔘 Several days 🔘 More than half the days 🔘 Nearly every day	167007AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
PHQ-9
Trouble falling asleep, staying asleep, or sleeping too much 🔘 Not at all 🔘 Several days 🔘 More than half the days	167068AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
Feeling tired or having little energy 🔘 Not at all 🔘 Several days 🔘 More than half the days 🔘 Nearly every day	167069AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
Poor appetite or overeating 🔘 Not at all 🔘 Several days 🔘 More than half the days 🔘 Nearly every day	167070AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
Feeling bad about yourself - or that you’re a failure or have let yourself or your family down 🔘 Not at all 🔘 Several days 🔘 More than half the days 🔘 Nearly every day	167071AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
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	167072AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
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	167073AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
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	167074AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
PHQ-9 score obtained by adding score for each question ___________________________	165137AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA
Notes	165095AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA