Patient Health Questionnaire Modified for Teens

Over the last 2 weeks, how often have you been                   Not at          Several          Over half          Nearly

bothered by the following problems:                                       all sure           days             the days        every day

1) Little interest or pleasure in doing things

2) Feeling down, depressed, or hopeless

3) Trouble falling asleep or staying asleep, or sleeping too much

4) Feeling tired or having little energy

5) Poor appetite or overeating

6) Feeling bad about yourself - or that you are a failure or have let yourself or your family down

7) Trouble concentrating on things, such as reading the newspaper or watching television

8) 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

9) Thoughts that you would be better off dead or hurting yourself in some way

add the score for each column=

TOTAL SCORE  (add your column scores) =

Over the last 2 weeks, how often have you been bothered by the following problems:

10) 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 other people?

11) In the past year, have you felt depressed or sad most days, even if you felt OK sometimes?

12) Has there been a time in the past month when you have had serious thoughts about ending your life?

13) Have you ever, in your whole life, tired to kill yourself or made a suicide attempt.

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Oak Harbor, WA 98277

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Freeland, WA 98249

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