Village Family Clinic & Wellness Center

PHQ-9

Name * Date * What prescriptions do you need refilled today?

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

1. Little interest or pleasure in doing things * 2. Feeling down, depressed, or hopeless * 3. Trouble falling or staying asleep, or sleeping too much * 4. Feeling tired or having little energy * 5. Poor appetite or overeating * 6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down * 7. Trouble concentrating on things, such as reading the newspaper or watching television * 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 * 9. Thoughts that you would be better off dead or thinking of hurting yourself in some way *

Please complete the questions below UNLESS you have already completed them on a different follow-up form.

Have you experienced any positive changes since your last visit? Any challenges? Are there any questions or concerns that you would like to address?

Thank you! Please press 'submit'.