San Jose Integrative Wellness Center
Patient Health Questionnaire
The following Patient Health Questionnaire is a multipurpose self-assessment to assist your physician in screening, diagnosing, and measuring the severity of depression.
Please use parent/guardian/caregiver phone number and email address if the patient is a minor, unless the minor has authority under applicable law to consent without parent/legal guardian.
Over the last two weeks, how often have you been bothered by any of the following problems?
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could notice. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself
Would you be interested in learning more about a safe, effective, non-drug treatment for depression?
How many anti-depressant prescription medications do you currently take or have tried in the past?
One or more questions were missed.
Please scroll up and provide answers to all questions.
