Pediatric Health Questionnaire DOWNLOAD PDF Pediatric Health Questionnaire NameDateOver the last 2 weeks, how often have you been bothered by any of the following problems? (use "" to indicate your answer)1. Little interest or pleasure in doing thingsNot at all (0)Several days (1)More than half the days (2)Nearly every day (3)2. Feeling down, depressed, or hopelessNot at all (0)Several days (1)More than half the days (2)Nearly every day (3)3. Trouble falling or staying asleep, or sleeping too muchNot at all (0)Several days (1)More than half the days (2)Nearly every day (3)4. Feeling tired or having little energyNot at all (0)Several days (1)More than half the days (2)Nearly every day (3)5. Poor appetite or overeatingNot at all (0)Several days (1)More than half the days (2)Nearly every day (3)6. Feeling bad about yourself-or that you are a failure or have let yourself or your family downNot at all (0)Several days (1)More than half the days (2)Nearly every day (3)7. Trouble concentrating on things, such as reading the newspaper or watching televisionNot at all (0)Several days (1)More than half the days (2)Nearly every day (3)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 usualNot at all (0)Several days (1)More than half the days (2)Nearly every day (3)9. Thoughts that you would be better off dead, or of hurting yourselfNot at all (0)Several days (1)More than half the days (2)Nearly every day (3)add columnsadd columnsadd columns(Healthcare professional: For interpretation of TOTAL, TOTAL: please refer to accompanying scoring card).10. 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 allSomewhat difficultVery difficultExtremely difficultFor initial diagnosis: 1. Patient completes PHQ-9 Quick Depression Assessment. 2. If there are at least 4s in the shaded section (including Questions #1 and #2), consider a depressive disorder. Add score to determine severity. Consider Major Depressive Disorder if there are at least 5s in the shaded section (one of which corresponds to Question #1 or #2) Consider Other Depressive Disorder - if there are 2-4s in the shaded section (one of which corresponds to Question #1 or #2) Note: Since the questionnaire relies on patient self-report, all responses should be verified by the clinician, and a definitive diagnosis is made on clinical grounds taking into account how well the patient understood the questionnaire, as well as other relevant information from the patient. Diagnoses of Major Depressive Disorder or Other Depressive Disorder also require impairment of social, occupational, or other important areas of functioning (Question #10) and ruling out normal bereavement, a history of a Manic Episode (Bipolar Disorder), and a physical disorder, medication, or other drug as the biological cause of the depressive symptoms. To monitor severity over time for newly diagnosed patients or patients in current treatment for depression: 1. Patients may complete questionnaires at baseline and at regular intervals (eg, every 2 weeks) at home and bring them in at their next appointment for scoring or they may complete the questionnaire during each scheduled appointment. 2. Add ups by column. For every: Several days = 1 More than half the days = 2 Nearly every day = 3 3. Add together column scores to get a TOTAL score. 4. Refer to the accompanying PHQ-9 Scoring Box to interpret the TOTAL score. 5. Results may be included in patient files to assist you in setting up a treatment goal, determining degree of response, as well as guiding treatment intervention. Scoring: add up all checked boxes on PHQ-9 For every Not at all = 0; Several days = 1; More than half the days = 2; Nearly every day = 3 Interpretation of Total ScoreSubmit form
