Patient Health Questionnaire (PHQ-9)

If you have been advised by the surgery to submit a Patient Health Questionnaire (PHQ-9) please use this form.

Last Updated: 17/08/2023

Your Details

Full Name *

Date of Birth *

Phone Number

Email Address *

Review Questionnaire

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

Rate by Scale

Please answer the following questions using the following scale:

0 - never avoid it, 8 - always avoid it

Social situations due to a fear of being embarrassed or making a fool of myself *

Certain Situations Because of a Fear of Having a Panic Attack or Other Distressing Symptoms (Such as Loss of Bladder Control, Vomiting or Dizziness) *

Certain Situations Because of a Fear of Particular Objects or Activities (Such as Animals, Heights, Seeing Blood, Being in Confined Spaces, Driving or Flying) *

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Patient Health Questionnaire (PHQ-9)

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