Ingrid Oliansky, Licensed Marriage and Family Therapist
​MFC# 48975
Call for an appointment (818) 927-3855
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Patient Health Questionnaire
Name:
Date:
Over the last two weeks, how often have you been bothered by any of the following problems?
1. Little Interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble Falling/Staying Asleep. Sleep   too much?
0                       1                                2                                                3 
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself- or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading or watching television.
8. Moving or speaking so slowly that people could have notices.Or the opposite; being so fidgety or restless that you have been moving around a lot more than usual.
9. Thoughts that you would be better off dead, or of hurting yourself
10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not at all
Several Days
More than half the days
Nearly Every Day
Not at all
Several Days
More than half the days
Nearly Every Day
Not at all
Several Days
More than half the days
Nearly Every Day
Not at all
Several Days
More than half the days
Nearly Every Day
Not at all
Several Days
More than half the days
Nearly Every Day
Not at all
Several Days
More than half the days
Nearly Every Day
Not at all
Several Days
More than half the days
Nearly Every Day
Not at all
Several Days
More than half the days
Nearly Every Day
Not at all
Several Days
More than half the days
Nearly Every Day
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult