Appointment
Appointment

*PHQ 9: Modified for Teens-Kids

Instructions: How often have you been bothered by each of the following symptoms during the past TWO weeks?

Patient Name(Required)
MM slash DD slash YYYY
1. Feeling down, depressed, irritable, or hopeless?(Required)
2. Little interest or pleasure in doing things?(Required)
3. Trouble falling asleep, staying asleep, or sleeping too much?(Required)
4. Poor appetite, weight loss, or overeating?(Required)
5. Feeling tired, or having little energy?(Required)
6. Feeling bad about yourself- or feeling that you are a failure, or that you have let yourself of your family down?(Required)
7. Trouble concentrating on things like school work, reading, or watching TV?(Required)
8. Moving or speaking so slowly that other people could have noticed? Or opposite: being so fidgety or restless that you were moving around a lot more than usual?(Required)
9. Thoughts that you would be better off dead, or of hurting yourself in some way?(Required)
In the PAST YEAR have you felt depressed or sad MOST days, even if you felt okay sometimes?(Required)
If you are experiencing any of the problems on this form, how DIFFICULT have these problems made it for you to do your school, work, take care of things at home or get along with other people?(Required)
Hs there been in a time in the PAST MONTH when you have had serious thoughts about ending your life?(Required)
Have you EVER in your WHOLE LIFE tried to kill yourself or made a suicide attempt?(Required)

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