Skip to main content

Private, consultant-led clinic. Not part of the NHS memory service. No GP referral needed.

Sheffield Memory Service & Geriatric Care Dr Pravin Jha · Consultant Geriatrician & Memory Specialist
WhatsApp 07873 258818 Contact us Book an appointment
Menu

Patient questionnaire

Depression and Anxiety Questionnaire (PHQ-9 and GAD-7)

Sixteen short questions about how often you have been bothered by low mood, worry and related problems over the last 2 weeks. There are no right or wrong answers. It takes about 5 minutes.

This form is for your appointment with Dr Jha. It is not checked out of hours, so please don’t use it for anything urgent: call 999 in an emergency, or NHS 111 or your GP for other urgent problems.

This questionnaire asks how often you have been bothered by some common problems over the last 2 weeks. There are no right or wrong answers. It takes about 5 minutes.

Your details

For example 12/03/1941

PHQ-9

Over the last 2 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 or staying asleep, or sleeping too much
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 the newspaper or watching television
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
9. Thoughts that you would be better off dead, or of hurting yourself in some way
If you ticked 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?

GAD-7

Over the last 2 weeks, how often have you been bothered by any of the following problems?
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it's hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
If you ticked 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?
Consent

Your answers are stored securely on this website for Dr Jha. They are copied into your clinical record and deleted from the website within 90 days. Privacy notice

Back to the pre-consultation questionnaires

Back to the 6-monthly review questionnaires