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Trouble falling or staying asleep, or sleeping too much. 4. Feeling tired or having little energy. 5. Poor appetite or overeating. 6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down. 7. Trouble concentrating on things, such as reading the newspaper or watching television.
(PHQ-9 and GAD-7) Date_____ Patient Name:_____ Date of Birth: _____ Over the last 2 weeks, how often have you been bothered by any of the following problems? Please circle your answers. PHQ-9 Not at all Several days More than half the days Nearly every day 1. Little interest or pleasure in doing things.
GAD-7 Not at all sure Several days Over half the days Nearly every day 1. Feeling nervous, anxious, or on edge. 2. Not being able to stop or control worrying. 3. Worrying too much about different things. 4. Trouble relaxing. 5. Being so restless that it’s hard to sit still. 6. Becoming easily annoyed or irritable. 7.
Feeling down, depressed, or hopeless. 3. Trouble falling or staying asleep, or sleeping too much. 4. Feeling tired or having little energy. 5. Poor appetite or overeating. 6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down.
PLEASE COMPLETE THE PHQ-9 AND GAD-7. t Name: DOB: Date of Referral: PHQ9023Over the last two weeks how often. ing the newspaper or watching televisionHMoving or speakin. so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that. Severe depression = 19 – 27 Total Score:If you checked off any problems ...
eralized Anxiety Disorder 7 (GAD-7)Over the past 2 weeks, how often have you been bother. ou. st. h. 3. i. il. thing awful might happen023“If you checked off any problems have these problems made it for your work, take care of things at h. ple? Not difficult at.
7 8 9 Little interest or pleasure in doing things Feeling down, depressed, or hopeless Trouble fall.ng or staying asleep, or sleeping too much Feeling tired or having little energy Poor appetite or overeating Feeling bad about yourself— or that you are a failure or have let yourself or your family down
Generalized Anxiety Disorder 7-item (GAD-7) scale Date: _______________ Name: _____________________________________ DOB: _______________ Over the last 2 weeks, how often have you been
Generalized Anxiety Disorder Patient Health Questionnaire (GAD-7/PHQ-9) Page 1 of 2 PATIENT LABEL. Generalized anxiety disorder (GAD-7) Patient name: Date: Screening questions. Over the last 2 weeks, how often have you been bothered by the following problems?
GAD-7 and PHQ-9 Measure to be completed for adults. MICE Measure/Record – PHQ-9 2 2 PHQ-9 (Depression) Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use “ ” to indicate your answer) day Not at all Several days More than half the days