Minor Participant Health Care Questionnaire Form

Minor Participant Health Care Questionnaire Form

PHQ-9. Over the last 2 weeks, how often have you been bothered by any of the following problems? Please answer each question.
Not at all (0pts)
Several Days (1 pt)
More than half the days (2 pts)
Nearly every day (3 pts)
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.

How difficult have these made it for you to do your work, take care of things at home, or get along with other people? Select your answer
GAD-7. Over the last 2 WEEKS, how often have you been bothered by any of the following problems? Please answer each question.
Not at all sure (0 pts)
Several days (1 pt)
Over half the days (2 pts)
Nearly every day (3 pts)
11. Feeling nervous, anxious, or on edge.
12. Not being able to stop or control worrying.
13. Worrying too much about different things.
14. Trouble relaxing
15. Being so restless that it’s hard to sit still
16. Becoming easily annoyed or irritable.
17. Feeling afraid as if something awful might happen.
GAD-7

How difficult have these made it for you to do your work, take care of things at home, or get along with other people? Select your answer

UHS Rev 4/2020

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc.
No permission required to reproduce, translate, display or distribute, 1999.