Patient Health Assessment (PHQ-9 / GAD-7)

If you have been advised by the surgery to submit a Patient Health Questionnaire (PHQ-9 and/or GAD-7) please use this form.

Last Updated: 14/04/2021

Your Details

Name *

Date of Birth *

Phone Number *

Email Address

Patient Health Review - Part 1

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 all

Several days

More than half the days

Nearly every day

Feeling down, depressed, or hopeless *

Not at all

Several days

More than half the days

Nearly every day

Trouble falling or staying asleep, or sleeping too much *

Not at all

Several days

More than half the days

Nearly every day

Feeling tired or having little energy *

Not at all

Several days

More than half the days

Nearly every day

Poor appetite or overeating *

Not at all

Several days

More than half the days

Nearly every day

Feeling bad about yourself — or that you are a failure or have let yourself or your family down *

Not at all

Several days

More than half the days

Nearly every day

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

Not at all

Several days

More than half the days

Nearly every day

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 *

Not at all

Several days

More than half the days

Nearly every day

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

Not at all

Several days

More than half the days

Nearly every day

If 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 all

Somewhat difficult

Very difficult

Extremely difficult

Patient Health Review - Part 2

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

Feeling nervous, anxious or on edge *

Not at all

Several Days

Over half the days

Nearly every day

Not being able to stop or control worrying *

Not at all

Several days

Over half the days

Nearly every day

Worrying too much about different things *

Not at all

Several days

Over half the days

Nearly every day

Having trouble relaxing *

Not at all

Several days

Over half the days

Nearly every day

Being so restless that it is hard to sit still *

Not at all

Several days

Over half the days

Nearly every day

Becoming easily annoyed or irritable *

Not at all

Several days

Over half the days

Nearly every day

Feeling afraid as if something awful might happen *

Not at all

Several days

Over half the days

Nearly every day

If 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 all

Somewhat difficult

Very difficult

Extremely difficult

THIS 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 form.

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Patient Health Assessment (PHQ-9 / GAD-7)

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