*PHQ 9: Modified for Teens-KidsInstructions: How often have you been bothered by each of the following symptoms during the past TWO weeks?Patient Name(Required) First Last Today Date(Required) MM slash DD slash YYYY Email(Required) 1. Feeling down, depressed, irritable, or hopeless?(Required) Not at all 0 Several days 1 More than half days 2 Nearly every day 32. Little interest or pleasure in doing things?(Required) Not at all 0 Several days 1 More than half days 2 Nearly every day 33. Trouble falling asleep, staying asleep, or sleeping too much?(Required) Not at all 0 Several days 1 More than half days 2 Nearly every day 34. Poor appetite, weight loss, or overeating?(Required) Not at all 0 Several days 1 More than half days 2 Nearly every day 35. Feeling tired, or having little energy?(Required) Not at all 0 Several days 1 More than half days 2 Nearly every day 36. Feeling bad about yourself- or feeling that you are a failure, or that you have let yourself of your family down?(Required) Not at all 0 Several days 1 More than half days 2 Nearly every day 37. Trouble concentrating on things like school work, reading, or watching TV?(Required) Not at all 0 Several days 1 More than half days 2 Nearly every day 38. 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) Not at all 0 Several days 1 More than half days 2 Nearly every day 39. Thoughts that you would be better off dead, or of hurting yourself in some way?(Required) Not at all 0 Several days 1 More than half days 2 Nearly every day 3In the PAST YEAR have you felt depressed or sad MOST days, even if you felt okay sometimes?(Required) Yes NoIf 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) Not difficult at all Somewhat difficult Very difficult Extremely difficultHs there been in a time in the PAST MONTH when you have had serious thoughts about ending your life?(Required) Yes NoHave you EVER in your WHOLE LIFE tried to kill yourself or made a suicide attempt?(Required) Yes NoSeverity Score:PATIENT/GUARDIAN SIGNATURE(Required)
