Neuropsych Adoloscent PHQ Form

Instructions: How often have you been bothered by each of the following symptoms during the past two weeks? For each symptom select the answer that best describes how you have been feeling.

1. Little interest or pleasure in doing things

0 - Not at all 1 - Several Days 2 - More than Half the Days 3 - Nearly Every Day

2. Feeling down, depressed or hopeless

0 - Not at all 1 - Several Days 2 - More than Half the Days 3 - Nearly Every Day

3. Trouble falling asleep, staying asleep, or sleeping too much

0 - Not at all 1 - Several Days 2 - More than Half the Days 3 - Nearly Every Day

4. Feeling tired or having little energy

0 - Not at all 1 - Several Days 2 - More than Half the Days 3 - Nearly Every Day

5. Poor appetite or overeating

0 - Not at all 1 - Several Days 2 - More than Half the Days 3 - Nearly Every Day

6. Feeling bad about yourself – or that you're a failure or have let yourself or your family down

0 - Not at all 1 - Several Days 2 - More than Half the Days 3 - Nearly Every Day

7. Trouble concentrating on things, such as reading the newspaper or watching television

0 - Not at all 1 - Several Days 2 - More than Half the Days 3 - 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

0 - Not at all 1 - Several Days 2 - More than Half the Days 3 - Nearly Every Day

9. Thoughts that you would be better off dead or of hurting yourself in some way

0 - Not at all 1 - Several Days 2 - More than Half the Days 3 - Nearly Every Day

If you checked off any problems, how difficult have those 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

How difficult have these problems made it for you?

Not difficult at all Somewhat difficult Very difficult Extremely difficult

Suicide Risk Assessment

Has there been a time in the past month when you have had serious thoughts about ending your life?

Yes No

Have you EVER, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?

Yes No

Important: If you have had thoughts that you would be better off dead or of hurting yourself in some way, please discuss this with your Health Care Clinician, go to a hospital emergency room or call 911.

Adolescent PHQ-9 (Patient Health Questionnaire)

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