Licensed GA Counselor Since 1991

Patient Health Questionnaire

Client's Name *

First

Last

Client's Birthday *

Over the last 2 weeks, how often have you been bothered by any of the following problems? *

	Not at all	Several days	More than half the days	Nearly every day
1. Little interest or pleasure in doing things	Not at all1. Little interest or pleasure in doing things Not at all	Several days1. Little interest or pleasure in doing things Several days	More than half the days1. Little interest or pleasure in doing things More than half the days	Nearly every day1. Little interest or pleasure in doing things Nearly every day
2. Feeling down, depressed, or hopeless	Not at all2. Feeling down, depressed, or hopeless Not at all	Several days2. Feeling down, depressed, or hopeless Several days	More than half the days2. Feeling down, depressed, or hopeless More than half the days	Nearly every day2. Feeling down, depressed, or hopeless Nearly every day
3. Trouble falling or staying asleep, or sleeping too much	Not at all3. Trouble falling or staying asleep, or sleeping too much Not at all	Several days3. Trouble falling or staying asleep, or sleeping too much Several days	More than half the days3. Trouble falling or staying asleep, or sleeping too much More than half the days	Nearly every day3. Trouble falling or staying asleep, or sleeping too much Nearly every day
4. Feeling tired or having little energy	Not at all4. Feeling tired or having little energy Not at all	Several days4. Feeling tired or having little energy Several days	More than half the days4. Feeling tired or having little energy More than half the days	Nearly every day4. Feeling tired or having little energy Nearly every day
5. Poor appetite or overeating	Not at all5. Poor appetite or overeating Not at all	Several days5. Poor appetite or overeating Several days	More than half the days5. Poor appetite or overeating More than half the days	Nearly every day5. Poor appetite or overeating Nearly every day
6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down	Not at all6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down Not at all	Several days6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down Several days	More than half the days6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down More than half the days	Nearly every day6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down Nearly every day
7. Trouble concentrating on things, such as reading the newspaper or watching television	Not at all7. Trouble concentrating on things, such as reading the newspaper or watching television Not at all	Several days7. Trouble concentrating on things, such as reading the newspaper or watching television Several days	More than half the days7. Trouble concentrating on things, such as reading the newspaper or watching television More than half the days	Nearly every day7. Trouble concentrating on things, such as reading the newspaper or watching television Nearly every day
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 all8. 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	Several days8. 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 Several days	More than half the days8. 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 More than half the days	Nearly every day8. 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 Nearly every day
9. Thoughts that you would be better off dead or of hurting yourself in some way	Not at all9. Thoughts that you would be better off dead or of hurting yourself in some way Not at all	Several days9. Thoughts that you would be better off dead or of hurting yourself in some way Several days	More than half the days9. Thoughts that you would be better off dead or of hurting yourself in some way More than half the days	Nearly every day9. Thoughts that you would be better off dead or of hurting yourself in some way Nearly every day

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? *

Not difficult at all	Somewhat difficult	Very difficult	Extremely difficult
Not difficult at allItem #1 Not difficult at all	Somewhat difficultItem #1 Somewhat difficult	Very difficultItem #1 Very difficult	Extremely difficultItem #1 Extremely difficult

Atlanta Counseling Solutions

We're More Than Just Talk

Patient Health Questionnaire