PHQ-9 - Vital Start Health

Perinatal Wellness Assessment – PHQ-9

1. Little interest or pleasure in doing things *

Not at all
Several days
More than half the days
Nearly every day

2. Feeling down, depressed, or hopeless *

Not at all
Several days
More than half the days
Nearly every day

3. Trouble falling or staying asleep, or sleeping too much *

Not at all
Several days
More than half the days
Nearly every day

4. Feeling tired or having little energy *

Not at all
Several days
More than half the days
Nearly every day

5. Poor appetite or overeating *

Not at all
Several days
More than half the days
Nearly every day

6. 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

7. 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

8. 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

9. 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

_{IF YOU THINK YOU ARE EXPERIENCING A MEDICAL EMERGENCY, CALL YOUR MEDICAL PROVIDER OR 911 IMMEDIATELY.}

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 difficult at all
Somewhat difficult
Very difficult
Extremely difficult

Name *

Date of Birth *//

Referring Provider Name

Referring Provider Email

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