Patient Health Assessment (PHQ-9) If you have been advised by the surgery to submit a Patient Health Questionnaire (PHQ-9) please use this form. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Your Details Name *FirstLast Feeling Data. staying Date of Birth *Phone NumberEmail Address *Patient Health Review Over the last 2 weeks, how often have you been bothered by any of the following problems? Little interest or pleasure in doing things *Not at allSeveral daysMore than half the daysNearly every dayFeeling down, depressed, or hopeless *Not at allSeveral daysMore than half the daysNearly every dayTrouble falling or staying asleep, or sleeping too much *Not at allSeveral daysMore than half the daysNearly every dayFeeling tired or having little energy *Not at allSeveral daysMore than half the daysNearly every dayPoor appetite or overeating *Not at allSeveral daysMore than half the daysNearly every dayFeeling bad about yourself — or that you are a failure or have let yourself or your family down *Not at allSeveral daysMore than half the daysNearly every dayTrouble concentrating on things, such as reading the newspaper or watching television *Not at allSeveral daysMore than half the daysNearly every dayMoving 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 allSeveral daysMore than half the daysNearly every dayThoughts that you would be better off dead or of hurting yourself in some way *Not at allSeveral daysMore than half the daysNearly every dayIf 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 allSomewhat difficultVery difficultExtremely difficultRate by Scale Please answer the following questions using the following scale: 0 – never avoid it, 2- slightly avoid it, 4 – definitely avoid it, 6 – markedly avoid it, 8 – always avoid it Social situations due to a fear of being embarrassed or making a fool of myself *— Select Choice —012345678Certain Situations Because of a Fear of Having a Panic Attack or Other Distressing Symptoms (Such as Loss of Bladder Control, Vomiting or Dizziness) *— Select Choice —012345678Certain Situations Because of a Fear of Particular Objects or Activities (Such as Animals, Heights, Seeing Blood, Being in Confined Spaces, Driving or Flying) *— Select Choice —012345678This Form Collects Your Name, Date of Birth, Email, Other Personal Information and Medical Details. This is to Confirm You Are Registered With the Practice, to Allow the Practice Team to Contact You and Also to Update Your Medical Records Held by the Practice and Our Partners in the Nhs. Please Read Our Privacy Policy to Discover How We Protect and Manage Your Submitted Data. *I consent to the practice collecting and storing my data from this formSubmit
