Patient Health Assessment (PHQ-9)

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

  • Your Details

    Date of Birth
    For example, 15 3 1984

  • Patient Health Review

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

    Little interest or pleasure in doing things
    Feeling down, depressed, or hopeless
    Trouble falling 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
    Trouble concentrating on things, such as reading the newspaper or watching television
    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
    Thoughts that you would be better off dead or of hurting yourself in some way
    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?

  • Rate by Scale

    Please answer the following questions using the following scale: 0 - never avoid it, 2- slightly avoid it, 4 - definitely avoid it, 6 - markedly avoid it, 8 - always avoid it

The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.
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Page last reviewed: 14 October 2026
Page created: 08 October 2026