Harmonious Mind
TMS of Wilmington
Patient Services
5189 W. Woodmill Dr., Wilmington, DE 19808 Tel: 302.633.6001 Fax: 302.295.6289
PHQ 9 Test
Fields with
*
are required.
First Name
*
MI
Last Name
*
DOB
*
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 so fidgety or restless that you have been moving 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 thoughts of hurting yourself in some way?
*
-
Not at all
Several days
More than half the days
Nearly every day
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