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PHQ9 & CAGE-AID
Do you have a few minutes to answer a short survey regarding your feelings in the last 2 weeks?
*
1.
Over the last 2 weeks, how often have you been bothered by any of the following problems?
(Required.)
Not at all
Several days
More than half the days
Nearly every day
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 thoughts of hurting yourself
Not at all
Several days
More than half the days
Nearly every day
2.
If you checked off ANY PROBLEMS...
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
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?
3.
If the survey result shows that you need a referral for help, can we contact you to provide you with a referral?
Name
Contact number