Adolescent PHQ-9 Form -

Today's Date

Patient Name

Clinician

Instructions: How often have you been bothered by each of the following symptoms during the past two weeks? For each symptom select box beneath the answer that best describes how you have been feeling.

Little interest or pleasure in doing things

0 – Not at all
1 – Several Days
2 – More than Half the Days
3 – Nearly Every Day

Feeling down, depressed or hopeless

0 – Not at all
1 – Several Days
2 – More than Half the Days
3 – Nearly Every Day

Trouble falling asleep, staying asleep, or sleeping too much

0 – Not at all
1 – Several Days
2 – More than Half the Days
3 – Nearly Every Day

Feeling tired or having little energy

0 – Not at all
1 – Several Days
2 – More than Half the Days
3 – Nearly Every Day

Poor appetite or overeating

0 – Not at all
1 – Several Days
2 – More than Half the Days
3 – Nearly Every Day

Feeling bad about yourself – or that you’re a failure or have let yourself or your family down

0 – Not at all
1 – Several Days
2 – More than Half the Days
3 – Nearly Every Day

Trouble concentrating on things, such as reading the newspaper or watching television

0 – Not at all
1 – Several Days
2 – More than Half the Days
3 – 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.

0 – Not at all
1 – Several Days
2 – More than Half the Days
3 – Nearly Every Day

Thoughts that you would be better off dead or of hurting yourself in some way

0 – Not at all
1 – Several Days
2 – More than Half the Days
3 – Nearly Every Day

If you checked off any problems, how difficult have those 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

Total Score (items 1-9)*

Total # Symptoms (scored 2 or 3)*

Please enter a number from 0 to 9.

Clinician Notes

Days depressed or sad

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?

Yes
No

How difficult

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

Past month

Has there been a time in the past month when you have had serious thoughts about ending your life?

Yes
No

Have you EVER, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?

Yes
No

Have you EVER, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?

Yes
No

**If you have had thoughts that you would be better off dead or of hurting yourself in some way, please discuss this with your Health Care Clinician, go to a hospital emergency room or call 911.