Patient Health Assessment (PHQ-9)

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

Last Updated: 27/09/2022

Your Details

Name *

Date of Birth *

Phone Number

Email Address *

Patient Health Review

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, 2- slightly avoid it, 4 - definitely avoid it, 6 - markedly 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) *

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

I consent to the practice collecting and storing my data from this form.

Patient Health Assessment (PHQ-9)

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