SCHWIETERS MEDICAL, PLLC

2781 Pilot Knob Road

Eagan, MN 55121
Phone: (651) 289-7300
Fax: (651) 289-7301

PHQ-9
Over the last 2 weeks, how often have you been bothered by the following problems?

Not at all Several days More than half Nearly every

1. Little interest or pleasure in
0 1 2 3
doing things
2. Feeling down, depressed or
0 1 2 3
hopeless
3. Trouble falling or staying
0 1 2 3
asleep, or sleeping too much
4. Feeling tired or having little
0 1 2 3
energy
5. Poor appetite or overeating 0 1 2 3
6. Feeling bad about yourself – or
that you are a failure or have let 0 1 2 3
yourself or your family down
7. Trouble concentrating on
things, such as reading the 0 1 2 3
newspaper or watching television
8. Moving or speaking so slowly
that other people could have
noticed? Or the opposite – being
0 1 2 3
so fidgety or restless that you have
been moving around a lot more
than usual

9. Thoughts that you would be

better off dead or of hurting 0 1 2 3
yourself in some way

TOTAL SCORE

________________ _____________+ _____________+ _____________+ _____________

If you chose any of the 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?

CIRCLE Not difficult at all Somewhat difficult Very difficult Extremely difficult
ONE:

Adrienne Thao
___________________________________________________________ 10/02/2023
________________________________
Printed Patient Name Date
Adapted and reproduced with permission from Spitzer, RL, Kroenke, K, Williams, JB, Lowe, B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med
2006; 166:1092. Copyright 2006 American Medical Association.