Patient Health QuestionnaireCJHTadmin2020-12-29T13:37:50+00:00 Patient Name* Date* MM slash DD slash YYYY Over the last two weeks, how often have you been bothered by the following problems? Not at all Several days Morethan half the days Nearly every day 1. Little interest or pleasure in doing things* 0 1 2 3 2. Feeling down, depressed, or hopeless* 0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much* 0 1 2 3 4. Feeling tired or having little energy* 0 1 2 3 5. Poor appetite or overeating* 0 1 2 3 6. Feeling bad about yourself or that you are a failure orhave let yourself or your family down* 0 1 2 3 7. Trouble concentrating on things, such as reading thenewspaper or watching television* 0 1 2 3 8. Moving or speaking so slowly that other people couldhave noticed. Or the opposite being so figety orrestless that you have been moving around a lot morethan usual* 0 1 2 3 9. Thoughts that you would be better off dead, or ofhurting yourself* 0 1 2 3 Total 0 If you checked any problems, how difficult have they 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
