PHQ-10 Self-Assessment Health Questionnaire

Soul Klinic

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.

Please enter your date of birth Please enter a valid date (mm/dd/yyyy)

Please provide your phone number

Please provide your email address Please enter a valid email address

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

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

2. Feeling down, depressed, or hopeless

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

3. Trouble falling or staying asleep, or sleeping too much

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

4. Feeling tired or having little energy

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

5. Poor appetite or overeating

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

6. Feeling bad about yourself – or that you are 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

7. 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

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

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

9. Thoughts that you would be better off dead, or of hurting yourself

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

Would you be interested in learning more about a safe, effective, non-drug treatment for depression?

Yes No

How many anti-depressant prescription medications do you currently take or have tried in the past?

2-4

Not Sure

One or more questions were missed.
Please scroll up and provide answers to all questions.