PHQ-9 This form is for current Kids Plus patients with a scheduled appointment. Your Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Today's Date(Required) MM slash DD slash YYYY Instructions & Acknowledgment(Required) I understand.This questionnaire relies on self-reporting -- so answer the questions by yourself without any parental involvement. Your answers will remain confidential when you submit them to us at Kids Plus. Please select one response for each question. 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.(Required) Not at all [1] Several days [2] More than half the days [3] Nearly every day 2. Feeling down, depressed, or hopeless(Required) Not at all [1] Several days [2] More than half the days [3] Nearly every day 3. Trouble falling or staying asleep, or sleeping too much(Required) Not at all [1] Several days [2] More than half the days [3] Nearly every day 4. Feeling tired or having little energy(Required) Not at all [1] Several days [2] More than half the days [3] Nearly every day 5. Poor appetite or overeating(Required) Not at all [1] Several days [2] More than half the days [3] Nearly every day 6. Feeling bad about yourself, or that you are a failure, or that you have let yourself or your family down(Required) Not at all [1] Several days [2] More than half the days [3] Nearly every day 7. Trouble concentrating on things, such as reading news or watching television(Required) 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've been moving around a lot more than usual(Required) 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(Required) Not at all [1] Several days [2] More than half the days [3] Nearly every day 10. If you checked any problems above, how difficult have these problems made it for you to go to work, take care of things at home, or get along with other people?(Required) Not at all [1] Somewhat difficult [2] Very difficult [3] Extremely difficult Thanks for completing this questionnaire. Please type your full name below and then submit the form by clicking the Submit button. By entering your name, you are acknowledging that you completed the entire form in private and without influence from a parent.(Required) CAPTCHA
