Mental Health Assessment Form

Questions	Concepts
PHQ-2
Screening Date ␣␣-␣␣-␣␣␣␣ 📆
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
PHQ-9
Trouble falling asleep, staying asleep, or sleeping too much 🔘 Not at all 🔘 Several days 🔘 More than half the days
Feeling tired or having little energy 🔘 Not at all 🔘 Several days 🔘 More than half the days 🔘 Nearly every day
5. Poor appetite or overeating 🔘 Not at all 🔘 Several days 🔘 More than half the days 🔘 Nearly every day
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
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
PHQ-9 score obtained by adding score for each question
Notes