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Overton Park Surgery NHS GP Surgery in Cheltenham

Patient Health Questionnaire (PHQ-9)

Patient Health Questionnaire (PHQ-9)

Who are you completing this form for?

For example, on behalf of a child or dependent

Yourself

Someone else

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

Review

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

Little interest or pleasure in doing things:

Not at all

Several days

More than half the days

Nearly every day

Feeling down, depressed, or hopeless:

Not at all

Several days

More than half the days

Nearly every day

Trouble falling or staying asleep, or sleeping too much:

Not at all

Several days

More than half the days

Nearly every day

Feeling tired or having little energy:

Not at all

Several days

More than half the days

Nearly every day

Poor appetite or overeating:

Not at all

Several days

More than half the days

Nearly every day

Feeling bad about yourself — or that you are a failure or have let yourself or your family down:

Not at all

Several days

More than half the days

Nearly every day

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

Not at all

Several days

More than half the days

Nearly every day

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

Several days

More than half the days

Nearly every day

Thoughts that you would be better off dead or of hurting yourself in some way:

Not at all

Several days

More than half the days

Nearly every day

For the following situations, please state how likely you are to avoid them using the following scores: 0 – Never avoid it, 2 – Slight 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

0

1

2

3

4

5

6

7

8

Certain situations because of a fear of having a panic attack or other distressing symptoms (such as loss of bladder control, vomiting or dizziness)

0

1

2

3

4

5

6

7

8

Certain situations because of a fear of particular objects or activities (such as animals, heights, seeing blood, being in confined spaces, driving or flying)

0

1

2

3

4

5

6

7

8

I confirm that the information provided is accurate to the best of my knowledge

If you are human, leave this field blank.

Forms not in use

We are currently not using this form. If you have a specific clinical request please call the surgery on 01242 580511. Thank you.

Overton Park Road
Cheltenham
GL50 3BP

Get directions

01242 580511

About the surgery

Register with the surgery

Sick (fit) notes

Feedback and complaints

Dr S Nelson & Partners

CQC overall rating

Good

7 October 2020

See the report

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