Mood Questionnaire (PHQ-9)

If you have been advised by the surgery to submit a Mood Questionnaire (PHQ-9) please use this form.

Only forms submitted in response to a GP request will be accepted.

Mood Questionnaire (PHQ-9)

Mood Questionnaire (PHQ-9)

About You

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

Review

Over the last 2 weeks, how often have you been bothered by any of the following problems:

Little interest or pleasure in doing things: *
Feeling down, depressed, or hopeless: *
Trouble falling or staying asleep, or sleeping too much: *
Feeling tired or having little energy: *
Poor appetite or overeating: *
Feeling bad about yourself — or that you are a failure or have let yourself or your family down: *
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: *
Thoughts that you would be better off dead or of hurting yourself in some way: *

For the following situations, please state how likely you are to avoid them using the following scores: 0 - Never avoid it, 2 - Slightly avoid it, 4 - Definitely avoid it, 6 - Markedly avoid it, 8 - Always avoid it.

Social situations due to a fear of being embarrassed or making a fool of myself *
Certain situations because of a fear of having a panic attack or other distressing symptoms (such as loss of bladder control, vomiting or dizziness) *
Certain situations because of a fear of particular objects or activities (such as animals, heights, seeing blood, being in confined spaces, driving or flying) *
*
Sending