Please complete the below form before next appointment. Thank you! PHQ – 9 Modified for Adolescents (PHQ-A)-Adapted Today's Date MM slash DD slash YYYY Email Name First Last Who will you be seeing today? Dr. Kefalas Angela Pellerito Melanie Troumbly Instructions: How often have you been bothered by each of the following symptoms during the past 7 days? For each symptom check the box that best describes how you have been feeling.Feeling down, depressed, or hopeless?* 0 Not at all 1 Several days 2 More than half the days 3 Nearly everyday Little interest or pleasure in doing things:* 0 Not at all 1 Several days 2 More than half the days 3 Nearly everyday Trouble falling or staying asleep, or sleeping too much:* 0 Not at all 1 Several days 2 More than half the days 3 Nearly everyday Poor appetite, weightloss, or overeating:* 0 Not at all 1 Several days 2 More than half the days 3 Nearly everyday Feeling tired or having little energy:* 0 Not at all 1 Several days 2 More than half the days 3 Nearly everyday Feeling bad about yourself — or that you are a failure or have let yourself or your family down:* 0 Not at all 1 Several days 2 More than half the days 3 Nearly everyday Trouble concentrating on things, such as school work, reading or watching TV.* 0 Not at all 1 Several days 2 More than half the days 3 Nearly everyday 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:* 0 Not at all 1 Several days 2 More than half the days 3 Nearly everyday Thoughts that you would be better off dead or of hurting yourself in some way:* 0 Not at all 1 Several days 2 More than half the days 3 Nearly everyday
