Required field(s) are indicated by * Patient Health Questionnaire (PHQ-9) Patient Health Questionnaire (PHQ-9) If you are human, leave this field blank. Are you completing this form on behalf of: Yourself Someone else (e.g. a child or dependent) About you Your First Name(s): * First Name(s) as appears on your passport. Your Last Name: * Last Name(s) as appears on your passport. Postcode: * The one used to register with your GP. Your Date of Birth: * Your date of birth is required to verify your identity. Sex: * Male Female Other As on your medical record. As on your medical record. Your Phone Number: * The practice may use this number to contact you about your request. Your Email: * This email address can be used to contact you about your request. Please be aware that if you have given anyone else access to your email account they may see responses sent to you. Please continue completing the form below 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: 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 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 Social situations due to a fear of being embarrassed or making a fool of myself 0 1 2 3 4 5 6 7 8 Certain situations because of a fear of having a panic attack or other distressing symptoms (such as loss of bladder control, vomiting or dizziness) 0 1 2 3 4 5 6 7 8 Certain situations because of a fear of particular objects or activities (such as animals, heights, seeing blood, being in confined spaces, driving or flying) 0 1 2 3 4 5 6 7 8 * I confirm that the information provided is accurate to the best of my knowledge