PHQ-10 Self-Assessment Health Questionnaire

OakLeaf Clinics - The Counseling Room

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?

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.

By pressing the 'Finished' button, you confirm that you are either an adult or a minor with the legal authority to consent without a parent or legal guardian, and consent to OakLeaf Clinics - The Counseling Room using automated technology to contact you.