Patient Health Questionnaire and General Anxiety Disorder (PHQ-9 and GAD-7) Date *Patient's Name *Date of Birth *PHQ-9Over the last 2 weeks, how often have you been bothered by any of the following problems? Please check your answer.1. Little interest or pleasure in doing things. *Not at all (0)Several days (1)More than half the days (2)Nearly every day (3)2. Feeling down, depressed, or hopeless. *Not at all (0)Several days (1)More than half the days (2)Nearly every day (3)3. Trouble falling or staying asleep, or sleeping too much. *Not at all (0)Several days (1)More than half the days (2)Nearly every day (3)4. Feeling tired or having little energy. *Not at all (0)Several days (1)More than half the days (2)Nearly every day (3)5. Poor appetite or overeating. *Not at all (0)Several days (1)More than half the days (2)Nearly every day (3)6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down. *Not at all (0)Several days (1)More than half the days (2)Nearly every day (3)7. Trouble concentrating on things, such as reading the newspaper or watching television. *Not at all (0)Several days (1)More than half the days (2)Nearly every day (3)8. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual. *Not at all (0)Several days (1)More than half the days (2)Nearly every day (3)9. Thoughts that you would be better off dead, or of hurting yourself in some way. *Not at all (0)Several days (1)More than half the days (2)Nearly every day (3)If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people? (Choose one) *Not difficult at allSomewhat difficultVery DifficultExtremely DifficultGAD-7Over the last 2 weeks, how often have you been bothered by any of the following problems? Please check your answer.1. Feeling nervous, anxious, or on edge. *Not difficult at all (0)Somewhat difficult (1)Very Difficult (2)Extremely Difficult (3)2. Not being able to stop or control worrying. *Not difficult at all (0)Somewhat difficult (1)Very Difficult (2)Extremely Difficult (3)3. Worrying too much about different things. *Not difficult at all (0)Somewhat difficult (1)Very Difficult (2)Extremely Difficult (3)4. Trouble relaxing. *Not difficult at all (0)Somewhat difficult (1)Very Difficult (2)Extremely Difficult (3)5. Being so restless that it’s hard to sit still. *Not difficult at all (0)Somewhat difficult (1)Very Difficult (2)Extremely Difficult (3)6. Becoming easily annoyed or irritable. *Not difficult at all (0)Somewhat difficult (1)Very Difficult (2)Extremely Difficult (3)7. Feeling afraid as if something awful might happen. *Not difficult at all (0)Somewhat difficult (1)Very Difficult (2)Extremely Difficult (3)If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people? (Choose one) *Not difficult at allSomewhat difficultVery DifficultExtremely DifficultConsent *Yes, I agree with the privacy policy and terms and conditions.Signature *Start signing your signature hereYour browser does not support e-Signature field.Send Message We're Here Whenever You Need Us Email [email protected] Phone (516)907-9243 Fax 855-844-6939 Address 319 Hempstead Ave, West Hempstead, NY, 11552 Quick Links Make Appointment About Contact Privacy Policy Forms Telehealth Consent Informed Consent for Assessment & Treatment Email/Text Consent Follow FollowFollowFollow
