Unit Kesihatan Awam

Hospital Canselor Tuanku Muhriz

HCTM
FAKULTI
UKM

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Patient Screening and Appointment

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

Full Name *

Phone *

Email Address *

Consent *

I agree to participate in this survey and understand that my information will be kept private and used only for healthcare purposes.

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

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

Little interest or pleasure in doing things *0123

Feeling down, depressed or hopeless *0123

Trouble falling or staying asleep, or sleeping too much *0123

Feeling tired or having little energy *0123

Poor appetite or overeating *0123

Feeling bad about yourself- or that you are a failure or have let yourself or your family down *0123

Trouble concentrating on things, such as reading the newspaper or watching television *0123

Moving or speaking so slowly that people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual *0123

Thoughts that you would be better off dead, or of hurting yourself *0123

Result PHQ-9

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

0 - Not at all sure

1 - Several days

2 - Over half the days

3 - Nearly every day

Feeling nervous, anxious, or on edge *0123

Not being able to stop or control worrying *0123

Worrying too much about different things *0123

Trouble relaxing *0123

Being so restless that it's hard to sit still *0123

Becoming easily annoyed or irritable *0123

Feeling afraid as if something awful might happen *0123

Result GAD-7

Consent *

I consent to the use of this data for medical research purposes.

Please do not fill in this field. Please do not fill in this field.

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HCTM

FAKULTI

UKM

PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

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