Date: _________
Gender: Male Female
Mood Assessment & PHQ-9
Below please choose the answers which appropriately sum up how you have felt over the previous two weeks.
Questions
Not at all
Several days
More than half the days 2
Nearly every day
0 How often have you had little pleasure or interest in doing things? How often have you by feeling down, depressed or hopeless? How often have you been bothered by trouble falling or staying asleep, or sleeping too much? How often have you been bothered by feeling tired or having little energy? How often have you been bothered by poor appetite or overeating? How often have you been bothered by feeling bad about yourself, or that you are a failure, or have let yourself or your family down? How often have you been bothered by trouble concentrating on things, such as reading the newspaper or watching the television? How often have you been bothered by 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? Have you had an anxiety attack? (suddenly feeling fear or panic) How often have you been bothered by feeling nervous, anxious or on edge? How often have you been bothered by not being able to stop or control worrying? How often have you been bothered by worrying too much about different things? How often have you been bothered by having trouble relaxing? How often have you been bothered by being so restless it is hard to sit still? How often have you been annoyed by becoming easily annoyed or irritable? How often have you been bothered by feeling afraid as if something bad is going to happen? If this questionnaire has highlighted 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? Have you been bothered by worrying about any of the following? Your health Your weight or how you look Little or no sexual desire or pleasure during sex Difficulties with your partner The stress of taking care of family members
Yes
No
Not at all Somewhat Very
Extremely
Stress at work, school or outside home By financial problems or worries Having no one to turn to Something bad that happened recently None of the above