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Patient Health Questionnaire

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

	Not at all	Several days	More than half the days	Nearly everyday
1. Little interest or pleasure in doing things	Not at all1. Little interest or pleasure in doing things Not at all	Several days1. Little interest or pleasure in doing things Several days	More than half the days1. Little interest or pleasure in doing things More than half the days	Nearly everyday1. Little interest or pleasure in doing things Nearly everyday
2. Feeling down, depressed, or hopeless	Not at all2. Feeling down, depressed, or hopeless Not at all	Several days2. Feeling down, depressed, or hopeless Several days	More than half the days2. Feeling down, depressed, or hopeless More than half the days	Nearly everyday2. Feeling down, depressed, or hopeless Nearly everyday
3. Trouble falling or staying asleep, or sleeping too much	Not at all3. Trouble falling or staying asleep, or sleeping too much Not at all	Several days3. Trouble falling or staying asleep, or sleeping too much Several days	More than half the days3. Trouble falling or staying asleep, or sleeping too much More than half the days	Nearly everyday3. Trouble falling or staying asleep, or sleeping too much Nearly everyday
4. Feeling tired or having little energy	Not at all4. Feeling tired or having little energy Not at all	Several days4. Feeling tired or having little energy Several days	More than half the days4. Feeling tired or having little energy More than half the days	Nearly everyday4. Feeling tired or having little energy Nearly everyday
5. Poor appetite or overeating	Not at all5. Poor appetite or overeating Not at all	Several days5. Poor appetite or overeating Several days	More than half the days5. Poor appetite or overeating More than half the days	Nearly everyday5. Poor appetite or overeating Nearly everyday
6. Feeling bad about yourself or that you are a failure or have let yourself or your family down	Not at all6. Feeling bad about yourself or that you are a failure or have let yourself or your family down Not at all	Several days6. Feeling bad about yourself or that you are a failure or have let yourself or your family down Several days	More than half the days6. Feeling bad about yourself or that you are a failure or have let yourself or your family down More than half the days	Nearly everyday6. Feeling bad about yourself or that you are a failure or have let yourself or your family down Nearly everyday
7. Trouble concentrating on things, such as reading the newspaper or watching television	Not at all7. Trouble concentrating on things, such as reading the newspaper or watching television Not at all	Several days7. Trouble concentrating on things, such as reading the newspaper or watching television Several days	More than half the days7. Trouble concentrating on things, such as reading the newspaper or watching television More than half the days	Nearly everyday7. Trouble concentrating on things, such as reading the newspaper or watching television Nearly everyday
8. Moving or speaking so slowly that other people could have noticed. Or the opposite being so figety or restless that you have been moving around a lot more than usual	Not at all8. Moving or speaking so slowly that other people could have noticed. Or the opposite being so figety or restless that you have been moving around a lot more than usual Not at all	Several days8. Moving or speaking so slowly that other people could have noticed. Or the opposite being so figety or restless that you have been moving around a lot more than usual Several days	More than half the days8. Moving or speaking so slowly that other people could have noticed. Or the opposite being so figety or restless that you have been moving around a lot more than usual More than half the days	Nearly everyday8. Moving or speaking so slowly that other people could have noticed. Or the opposite being so figety or restless that you have been moving around a lot more than usual Nearly everyday
9.Thoughts that you would be better off dead, or of hurting yourself	Not at all9.Thoughts that you would be better off dead, or of hurting yourself Not at all	Several days9.Thoughts that you would be better off dead, or of hurting yourself Several days	More than half the days9.Thoughts that you would be better off dead, or of hurting yourself More than half the days	Nearly everyday9.Thoughts that you would be better off dead, or of hurting yourself Nearly everyday

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

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The Mood Disorder Questionnaire

1. Has there ever been a period of time when you were not your usual self and...

	Yes	No
...you felt so good or so hyper that other people thought you were not your "normal" self or you were so hyper that you got into trouble?	Yes...you felt so good or so hyper that other people thought you were not your "normal" self or you were so hyper that you got into trouble? Yes	No...you felt so good or so hyper that other people thought you were not your "normal" self or you were so hyper that you got into trouble? No
...you were so irritable that you shouted at people or started fights or arguments?	Yes...you were so irritable that you shouted at people or started fights or arguments? Yes	No...you were so irritable that you shouted at people or started fights or arguments? No
...you felt much more self-confident than usual?	Yes...you felt much more self-confident than usual? Yes	No...you felt much more self-confident than usual? No
...you got much less sleep than usual and found you didn’t really miss it?	Yes...you got much less sleep than usual and found you didn’t really miss it? Yes	No...you got much less sleep than usual and found you didn’t really miss it? No
...you were much more talkative or spoke much faster than usual?	Yes...you were much more talkative or spoke much faster than usual? Yes	No...you were much more talkative or spoke much faster than usual? No
...thoughts raced through your head or you couldn’t slow your mind down?	Yes...thoughts raced through your head or you couldn’t slow your mind down? Yes	No...thoughts raced through your head or you couldn’t slow your mind down? No
...you were so easily distracted by things around you that you had trouble concentrating or staying on track?	Yes...you were so easily distracted by things around you that you had trouble concentrating or staying on track? Yes	No...you were so easily distracted by things around you that you had trouble concentrating or staying on track? No
...you had much more energy than usual?	Yes...you had much more energy than usual? Yes	No...you had much more energy than usual? No
...you were much more active or did many more things than usual?	Yes...you were much more active or did many more things than usual? Yes	No...you were much more active or did many more things than usual? No
...you were much more social or outgoing than usual, for example, you " " telephoned friends in the middle of the night?	Yes...you were much more social or outgoing than usual, for example, you " " telephoned friends in the middle of the night? Yes	No...you were much more social or outgoing than usual, for example, you " " telephoned friends in the middle of the night? No
...you were much more interested in sex than usual?	Yes...you were much more interested in sex than usual? Yes	No...you were much more interested in sex than usual? No
...you did things that were unusual for you or that other people might have " " thought were excessive, foolish, or risky?	Yes...you did things that were unusual for you or that other people might have " " thought were excessive, foolish, or risky? Yes	No...you did things that were unusual for you or that other people might have " " thought were excessive, foolish, or risky? No
...spending money got you or your family into trouble?	Yes...spending money got you or your family into trouble? Yes	No...spending money got you or your family into trouble? No

	Yes	No
2.If you checked YES to more than one of the above, have several of these ever happened during the same period of time?	Yes2.If you checked YES to more than one of the above, have several of these ever happened during the same period of time? Yes	No2.If you checked YES to more than one of the above, have several of these ever happened during the same period of time? No

3. How much of a problem did any of these cause you – like being unable to work; having family, money or legal troubles; getting into arguments or fights?

No Problem
Minor Problem
Moderate Problem
Serious Problem

	Yes	No
4. Have any of your blood relatives (i.e. children, siblings, parents, grandparents, " " aunts, uncles) had manic-depressive illness or bipolar disorder?	Yes4. Have any of your blood relatives (i.e. children, siblings, parents, grandparents, " " aunts, uncles) had manic-depressive illness or bipolar disorder? Yes	No4. Have any of your blood relatives (i.e. children, siblings, parents, grandparents, " " aunts, uncles) had manic-depressive illness or bipolar disorder? No

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Generalized Anxiety Disorder 7-item (GAD-7) scale

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

	0 - Not sure at all	1 - Several days	2 - Over half the days	3 - Mostly everyday
1. Feeling nervous, anxious, or on edge	0 - Not sure at all1. Feeling nervous, anxious, or on edge 0 - Not sure at all	1 - Several days1. Feeling nervous, anxious, or on edge 1 - Several days	2 - Over half the days1. Feeling nervous, anxious, or on edge 2 - Over half the days	3 - Mostly everyday1. Feeling nervous, anxious, or on edge 3 - Mostly everyday
2. Not being able to stop or control worrying	0 - Not sure at all2. Not being able to stop or control worrying 0 - Not sure at all	1 - Several days2. Not being able to stop or control worrying 1 - Several days	2 - Over half the days2. Not being able to stop or control worrying 2 - Over half the days	3 - Mostly everyday2. Not being able to stop or control worrying 3 - Mostly everyday
3. Worrying too much about different things	0 - Not sure at all3. Worrying too much about different things 0 - Not sure at all	1 - Several days3. Worrying too much about different things 1 - Several days	2 - Over half the days3. Worrying too much about different things 2 - Over half the days	3 - Mostly everyday3. Worrying too much about different things 3 - Mostly everyday
4. Trouble relaxing	0 - Not sure at all4. Trouble relaxing 0 - Not sure at all	1 - Several days4. Trouble relaxing 1 - Several days	2 - Over half the days4. Trouble relaxing 2 - Over half the days	3 - Mostly everyday4. Trouble relaxing 3 - Mostly everyday
5. Being so restless that it's hard to sit still	0 - Not sure at all5. Being so restless that it's hard to sit still 0 - Not sure at all	1 - Several days5. Being so restless that it's hard to sit still 1 - Several days	2 - Over half the days5. Being so restless that it's hard to sit still 2 - Over half the days	3 - Mostly everyday5. Being so restless that it's hard to sit still 3 - Mostly everyday
6. Becoming easily annoyed or irritable	0 - Not sure at all6. Becoming easily annoyed or irritable 0 - Not sure at all	1 - Several days6. Becoming easily annoyed or irritable 1 - Several days	2 - Over half the days6. Becoming easily annoyed or irritable 2 - Over half the days	3 - Mostly everyday6. Becoming easily annoyed or irritable 3 - Mostly everyday
7. Feeling afraid as if something awful might happen	0 - Not sure at all7. Feeling afraid as if something awful might happen 0 - Not sure at all	1 - Several days7. Feeling afraid as if something awful might happen 1 - Several days	2 - Over half the days7. Feeling afraid as if something awful might happen 2 - Over half the days	3 - Mostly everyday7. Feeling afraid as if something awful might happen 3 - Mostly everyday

Total Score (add your column scores) =

If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?

Name *

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