Mental Health Assessment Form

Questions	Concepts
PHQ-2
Screening Date ␣␣-␣␣-␣␣␣␣ 📆	160753 Date of event
Little interest or pleasure in doing things 🔘 Not at all 🔘 Several days 🔘 More than half the days 🔘 Nearly every day	167006 Little interest or pleasure in doing things over past two weeks
Feeling down, depressed or hopeless 🔘 Not at all 🔘 Several days 🔘 More than half the days 🔘 Nearly every day	167007 Feeling down, depressed, or hopeless over past two weeks
PHQ-9
Trouble falling asleep, staying asleep, or sleeping too much 🔘 Not at all 🔘 Several days 🔘 More than half the days	167068 Trouble falling or staying asleep, or sleeping too much over past two weeks
Feeling tired or having little energy 🔘 Not at all 🔘 Several days 🔘 More than half the days 🔘 Nearly every day	167069 Feeling tired or having little energy over past two weeks
Poor appetite or overeating 🔘 Not at all 🔘 Several days 🔘 More than half the days 🔘 Nearly every day	167070 Poor appetite or overeating over past two weeks
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	167071 Feeling bad about yourself or that you're a failure or have let yourself or your family down
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	1167072 Trouble concentrating on things such as reading the newspaper or watching television
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	167073 Moving or speaking so slowly that other people could have noticed or being so fidgety or restless that you have been moving around lot more than usual
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	167074 Thoughts that you would be better off dead or of hurting yourself in some way
PHQ-9 score obtained by adding score for each question ___________________________	165137 Patient Health Questionnaire Nine Item score
Notes	165095 General patient note