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Patient Health Questionnaire (PHQ-9)

If you have been advised by the surgery to submit a mental health review (PHQ-9) please use this form.This form should not be used to access urgent help and may take up to 5 working days to be processed. If you require urgent help regarding your mental health, please visit 'I need help now' or speak to one of our medical receptionists by calling 01642 618170

Full Name:


Date of Birth:


Phone Number:


Email Address:


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

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 dayy

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 the opposite — being so fidgety or restless that you have been moving around 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 of hurting yourself in some way:
Not at all
Several days
More than half the days
Nearly every day

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?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult

I confirm that the information provided is accurate to the best of my knowledge.

I confirm that I am currently within the UK at the time of sending my enquiry.