Patient Health Questionnaire-9 for ADOLESCENTS ("PHQ-A") for Collaborative Solutions in Psychiatry
For patients age 18 or younger ONLY:  Please complete this questionnaire before your appointment.
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Your full first and last name *
Over the past seven days, how often have you been bothered by any of the following problems?  0 = Not at all; 1 = Several days; 2 = More than half the days; 3 = Nearly every day. *
0
1
2
3
Feeling down, depressed, irritable, or hopeless?
Little interest or pleasure in doing things?
Trouble falling or staying asleep, or sleeping too much?
Poor appetite, weight loss, or overeating?
Feeling tired, or having little energy?
Feeling bad about yourself - or that you are a failure or have let yourself or your family down?
Trouble concentrating on things, such as schoolwork, reading, or watching TV?
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?
In the past year, have you felt depressed or sad most days, even if you felt okay sometimes?
Clear selection
If you are experiencing any of the problems on this form, how difficult have these problems made it for you to do your work, take care of things at home, or get along with others? *
Has there been a time in the past month that you have had serious thoughts about ending your life?
Clear selection
Have you ever, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?
Clear selection
**If you have had thoughts that you'd be better off dead or of hurting yourself in some way, please discuss this with your health care provider.**
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