Health and General Anxiety Disorder Questionnaire (PHQ-9 and GAD-7) Date MM DD YYYY Name * First Name Last Name 1. Over the last 2 weeks, how often have you been bothered by the following concern? Please select your answer. Little interest or pleasure in doing things. Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) 2. Over the last 2 weeks, how often have you been bothered by the following concern? Please select your answer. Feeling down, depressed, or hopeless. Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) 3. Over the last 2 weeks, how often have you been bothered by the following concern? Please select your answer. Trouble falling or staying asleep, or sleeping too much. Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) 4. Over the last 2 weeks, how often have you been bothered by the following concern? Please select your answer. Feeling tired or having little energy. Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) 5. Over the last 2 weeks, how often have you been bothered by the following concern? Please select your answer. Poor appetite or overeating. Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) 6. Over the last 2 weeks, how often have you been bothered by the following concern? Please select your answer. Feeling bad about yourself—or that you are a failure or have let yourself or your family down. Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) 7. Over the last 2 weeks, how often have you been bothered by the following concern? Please select your answer. Trouble concentrating on things, such as reading the newspaper or watching television. Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) 8. Over the last 2 weeks, how often have you been bothered by the following concern? Please select your answer. 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. Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) 9. Over the last 2 weeks, how often have you been bothered by the following concern? Please select your answer. Thoughts that you would be better off dead, or of hurting yourself in some way. Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) Add together the score for each of the previous nine questions (PHQ-9). 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? (Choose one) Not difficult at all Somewhat difficult Very Difficult Extremely Difficult Over the last 2 weeks, how often have you been bothered by the following concern? Please select your answer. Feeling nervous, anxious, or on edge. Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) 1. Over the last 2 weeks, how often have you been bothered by the following concern? Please select your answer. Not being able to stop or control worrying. Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) 2. Over the last 2 weeks, how often have you been bothered by the following concern? Please select your answer. Worrying too much about different things. Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) 3. Over the last 2 weeks, how often have you been bothered by the following concern? Please select your answer. Trouble relaxing. Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) 4. Over the last 2 weeks, how often have you been bothered by the following concern? Please select your answer. Being so restless that it’s hard to sit still. Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) 5. Over the last 2 weeks, how often have you been bothered by the following concern? Please select your answer. Becoming easily annoyed or irritable. Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) 6. Over the last 2 weeks, how often have you been bothered by the following concern? Please select your answer. Feeling afraid as if something awful might happen. Not at all (0) Several days (1) More than half the days (2) Nearly every day (3) Add together the score for each of the previous seven questions (GAD-7). 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? (Choose one) Not difficult at all Somewhat difficult Very Difficult Extremely Difficult Thank you!
