Quick Guide to PRIME-MD Patient Health Questionnaire (PHQ)

**Purpose.** The Patient Health Questionnaire (PHQ) is designed to
facilitate the recognition and diagnosis of the most common mental
disorders in primary care patients. For patients with a depressive
disorder, a PHQ Depression Severity Index score can be calculated and
repeated over time to monitor change.

**Who Should Take the PHQ.** Ideally, the PHQ should be used with all
new patients, all patients who have not completed the questionnaire in
the last year, and all patients suspected of having a mental disorder.

**Making a Diagnosis.** Since the questionnaire relies on patient
self-report, definitive diagnoses must be verified by the clinician,
taking into account how well the patient understood the questions in the
questionnaire, as well as other relevant information from the patient,
his or her family or other sources.

**Interpreting the PHQ.** To facilitate interpretation of patient
responses, all clinically significant responses are found in the column
farthest to the right. (The only exception is for suicidal ideation when
diagnosing a depressive syndrome.) At the bottom of each page, beginning
with "FOR OFFICE CODING", in small type, are criteria for diagnostic
judgments for summarizing the responses on that page. The names of the
categories are abbreviated, e.g., Major Depressive Syndrome is Maj Dep
Syn..

**Page 1**

Somatoform Disorder if at least 3 of #1a-m bother the patient "a lot"
and lack an adequate biological explanation.\
Major Depressive Syndrome if #2a or b and five or more of #2a-i are at
least "More than half the days" (count #2i if present at all) .\
Other Depressive Syndrome if #2a or b and two, three, or four of #2a-i
are at least "More than half the days" (count #2i if present at all).\
\
**Note:** the diagnoses of Major Depressive [Disorder]{.underline} and
Other Depressive [Disorder]{.underline} requires ruling out normal
**bereavement (mild symptoms, duration less than 2 months)**, a history
of a **manic** episode (Bipolar Disorder) and a **physical disorder,
medication or other drug** as the biological cause of the depressive
symptoms.

**Page 2**

Panic Syndrome if #3a-d are all 'YES' and 4 or more of #4a-k are 'YES'.\
Other Anxiety Syndrome if #5a and answers to three or more of #5b-g are
"More than half the days".

**Note:** The diagnoses of Panic [Disorder]{.underline} and Other
Anxiety [Disorder]{.underline} require ruling out a **physical disorder,
medication or other drug** as the biological cause of the anxiety
symptoms.

**Page 3**

Bulimia Nervosa if #6a,b, and c and #8 are 'YES'; Binge Eating Disorder
the same but #8 is either 'NO' or left blank.

Alcohol abuse if any of #10a-e are "YES".

**Additional Clinical Considerations.** After making a provisional
diagnosis with the PHQ, there are additional clinical considerations
that may affect decisions about management and treatment.

*Have current symptoms been triggered by psychosocial **stressor(s**)?*

*What is the **duration** of the current disturbance and has the patient
received any **treatment** for it?*

*To what extent are the patient's symptoms i**mpairing** his or her
usual work and activities?*

*Is there a **history** of similar episodes, and were they **treated**?*

*Is there a **family history** of similar conditions?*

**Example of Diagnosing Major Depressive Disorder & Calculating PHQ-9
Depression Severity**

**Patient:** A 43-year-old woman who looks sad and complains of fatigue
for the past month.

+---------------------------------------------+----+---+-----+-----+-----+
| > **2. Over the [last 2 weeks]{.underline}, | *  |   | **\ | **M | **  |
| > how often have you been bothered by any   | *\ |   | S   | ore | Nea |
| > of the following:**                       | \  |   | eve | t   | rly |
|                                             | N  |   | ral | han | eve |
|                                             | ot |   | day | h   | ry\ |
|                                             | at |   | s** | alf | da  |
|                                             | a  |   |     | the | y** |
|                                             | ll |   |     | day |     |
|                                             | ** |   |     | s** |     |
+---------------------------------------------+----+---+-----+-----+-----+
|                                             | \  |   | \(  | \(  | \(  |
|                                             | (0 |   | 1\) | 2\) | 3\) |
|                                             | \) |   |     |     |     |
+---------------------------------------------+----+---+-----+-----+-----+
| a.  Little interest or pleasure in doing    |   |   |    |    |    |
|     things?....................             |    |   |     |     |     |
+---------------------------------------------+----+---+-----+-----+-----+
| b.  Feeling down, depressed, or             |   |   |    |    |    |
|     hopeless?.......................        |    |   |     |     |     |
+---------------------------------------------+----+---+-----+-----+-----+
| c.  Trouble falling or staying asleep, or   |   |   |    |    |    |
|     sleeping too much?                      |    |   |     |     |     |
+---------------------------------------------+----+---+-----+-----+-----+
| d.  Feeling tired or having little          |   |   |    |    |    |
|     energy?\...\...\............\.......... |    |   |     |     |     |
+---------------------------------------------+----+---+-----+-----+-----+
| e.  Poor appetite or                        |   |   |    |    |    |
|     overeating?\..                          |    |   |     |     |     |
| .\...\...\...\...\...\..................... |    |   |     |     |     |
+---------------------------------------------+----+---+-----+-----+-----+
| f.  Feeling bad about yourself---or that    |   |   |    |    |    |
|     you are a failure or have let yourself  |    |   |     |     |     |
|     or your family                          |    |   |     |     |     |
|     down?.......................            |    |   |     |     |     |
+---------------------------------------------+----+---+-----+-----+-----+
| g.  Trouble concentrating on things, such   |   |   |    |    |    |
|     as reading the newspaper or watching    |    |   |     |     |     |
|     television? ..........................  |    |   |     |     |     |
+---------------------------------------------+----+---+-----+-----+-----+
| h.  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?\...\...\...\........             |    |   |     |     |     |
| ........................................... |    |   |     |     |     |
+---------------------------------------------+----+---+-----+-----+-----+
| i.  Thoughts that you would be better off   |   |  |     |    |    |
|     dead or of hurting yourself in some     |    |   |     |     |     |
|     way?                                    |    |   |     |     |     |
|                                             |    |   |     |     |     |
| ........................................... |    |   |     |     |     |
+---------------------------------------------+----+---+-----+-----+-----+
| \_\_\_\_\_\_\_\_\_\_                        |    |   |     |     |     |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |    |   |     |     |     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |    |   |     |     |     |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\ |    |   |     |     |     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |    |   |     |     |     |
|                                             |    |   |     |     |     |
| > FOR OFFICE CODING: Maj Dep Syn if #2a or  |    |   |     |     |     |
| > b and five or more of #2a-i are at least  |    |   |     |     |     |
| > "More than half the days" (count #2i if   |    |   |     |     |     |
| > present at all) . Other Dep Syn if #2a or |    |   |     |     |     |
| > b and two, three, or four of #2a-i are at |    |   |     |     |     |
| > least "More than half the days" (count    |    |   |     |     |     |
| > #2i if present at all).                   |    |   |     |     |     |
+---------------------------------------------+----+---+-----+-----+-----+

**Major Depressive Disorder Diagnosis.** The criteria for Major
Depressive [Syndrome]{.underline} are met since she checked #2a "nearly
every day" and five of items #2a to i were checked "'more than half the
days" or "nearly every day". [Note that #2i, suicidal ideation, is
counted whenever it is present.]{.underline}

In this case, the diagnosis of Major Depressive [Disorder]{.underline}
(not Syndrome) was made since questioning by the physician indicated no
history of a manic episode; no evidence that a physical disorder,
medication, or other drug caused the depression; and no indication that
the depressive symptoms were normal bereavement. Questioning about the
suicidal ideation indicated no significant suicidal potential.

**PHQ-9 Depression Severity.** This is calculated by assigning scores of
0, 1, 2, and 3, to the response categories of "not at all," "several
days," "more than half the days," and "nearly every day," respectively.
The Index is the sum of the scores for the nine items, and ranges from 0
to 27. In the above case, the PHQ-9 depression severity score is 16 (3
items scored 1, 2 items scored 2, and 3 items scored 3). Scores of 5,
10, 15, and 20 represent cutpoints for mild, moderate, moderately severe
and severe depression, respectively.

**PHQ-15 Somatic Symptom Severity**. This is calculated by assigning
scores of 0, 1, and 2 to the response categories of "not at all",
"bothered a little", and "bothered a lot", for the 13 somatic symptoms.
Also, 2 items from the mood module (fatigue and sleep) are scored 0
("not at all"), 1 ("several days") or 2 ("more than half the days" or
"nearly every day"). Scores of 5, 10, and 15 represent cutpoints for
low, medium, and high somatic symptom severity, respectively.

#### References

Spitzer RL, Kroenke K, Williams JBW, for the Patient Health
Questionnaire Primary Care Study Group. Validation and utility of a
self-report version of PRIME-MD: the PHQ Primary Care Study. JAMA
1999;282:1737-1744.

Spitzer RL, Williams JBW, Kroenke K, et al. Validity and utility of the
Patient Health Questionnaire in assessment of 3000
obstetrics-gynecologic patients. Am J Obstet Gynecol 2000; 183:759-769

Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: Validity of a brief
depression severity measure. J Gen Intern Med 2001;16:606-613.

Kroenke K, Spitzer RL, Williams JBW. The PHQ-15: Validity of a new
measure for evaluating somatic symptom severity. Psychosom Med
2002;64:258-266.

Kroenke K, Spitzer RL. The PHQ-9: a new depression diagnostic and
severity measure. Psychiatric Annals (in press).

#### PHQ-9 Scores and Proposed Treatment Actions \*

+-------+---------+----------------------------------------------------+
| **    | **Dep   | #### Proposed Treatment Actions                    |
| PHQ-9 | ression |                                                    |
| Sc    | Sev     |                                                    |
| ore** | erity** |                                                    |
+-------+---------+----------------------------------------------------+
| 1 --  | None    | None                                               |
| 4     |         |                                                    |
+-------+---------+----------------------------------------------------+
| 5 --  | Mild    | Watchful waiting; repeat PHQ-9 at follow-up        |
| 9     |         |                                                    |
+-------+---------+----------------------------------------------------+
| 10 -- | M       | Treatment plan, considering counseling, follow-up  |
| 14    | oderate | and/or pharmacotherapy                             |
+-------+---------+----------------------------------------------------+
| 15 -- | Mod     | Immediate initiation of pharmacotherapy and/or     |
| 19    | erately | psychotherapy                                      |
|       | Severe  |                                                    |
+-------+---------+----------------------------------------------------+
| 20 -- | Severe  | Immediate initiation of pharmacotherapy and, if    |
| 27    |         | severe impairment or poor response to therapy,     |
|       |         | expedited referral to a mental health specialist   |
|       |         | for psychotherapy and/or collaborative management  |
+-------+---------+----------------------------------------------------+

\* From Kroenke K, Spitzer RL, Psychiatric Annals (in press).

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke
and colleagues, with an educational grant from Pfizer Inc. For research
information, contact Dr. Spitzer at <rls8@columbia.edu> or Dr. Kroenke
at <kkroenke@regenstrief.org> The names PRIME-MD® and PRIME-MD TODAY®
are trademarks of Pfizer Inc.

On the following pages are the

-   Full PHQ

-   PHQ-15 somatic symptom subscale

-   PHQ-9 depression subscale

-   

**Patient Health Questionnaire**

**This questionnaire is an important part of providing you with the best
health care possible. Your answers will help in understanding problems
that you may have. Please answer every question to the best of your
ability unless you are requested to skip over a question.**

**Name\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Age\_\_\_\_\_ Sex:**
**Female** **Male Today's Date\_\_\_\_\_\_\_\_**

+--------------------------------------------+-------+--------+-------+
| 1\. **During the [last 4                   | **\   | **\    | **\   |
| weeks]{.underline}, how much have you      | Not   | Bot    | Both  |
| been\                                      | bothe | hered\ | ered\ |
| bothered by any of the following           | red** | a      | a     |
| problems?**                                |       | li     | lot** |
|                                            |       | ttle** |       |
+--------------------------------------------+-------+--------+-------+
| a.  Stomach                                |       |        |       |
|     pain\...\...\...\...\...\...\          |       |        |       |
| ...\...\...\...\.......................... |       |        |       |
+--------------------------------------------+-------+--------+-------+
| b.  Back                                   |       |        |       |
|     pain\...\...\...\...\...\...\...\..    |       |        |       |
| .\...\...\...\............................ |       |        |       |
+--------------------------------------------+-------+--------+-------+
| c.  Pain in your arms, legs, or joints     |       |        |       |
|     (knees, hips, etc.)\...                |       |        |       |
+--------------------------------------------+-------+--------+-------+
| d.  Menstrual cramps or other problems     | **\   | **\    | **\   |
|     with your                              | **    | **     | **    |
|     periods..................              |       |        |       |
| .......................................... |       |        |       |
+--------------------------------------------+-------+--------+-------+
| e.  Pain or problems during sexual         |       |        |       |
|     intercourse.............               |       |        |       |
+--------------------------------------------+-------+--------+-------+
| f.                                         |       |        |       |
|   Headaches\...\...\...\...\...\...\...\.. |       |        |       |
| .\...\...\...\...\........................ |       |        |       |
+--------------------------------------------+-------+--------+-------+
| g.  Chest                                  |       |        |       |
|     pain\...\...\...\...\...\...\...\...   |       |        |       |
| \...\...\...\...\......................... |       |        |       |
+--------------------------------------------+-------+--------+-------+
| h.                                         |       |        |       |
|  Dizziness.....\...\...\...\...\...\...\.. |       |        |       |
| .\...\...\...\...\........................ |       |        |       |
+--------------------------------------------+-------+--------+-------+
| i.  Fainting                               |       |        |       |
|     spells\...\...\...\...\...\...         |       |        |       |
| \...\...\...\...\......................... |       |        |       |
+--------------------------------------------+-------+--------+-------+
| j.  Feeling your heart pound or            |       |        |       |
|     race\...........................       |       |        |       |
+--------------------------------------------+-------+--------+-------+
| k.  Shortness of                           |       |        |       |
|     breath\...\...\..                      |       |        |       |
| .\...\...\...\............................ |       |        |       |
+--------------------------------------------+-------+--------+-------+
| l.  Constipation, loose bowels, or         |       |        |       |
|     diarrhea..................             |       |        |       |
+--------------------------------------------+-------+--------+-------+
| m.  Nausea, gas, or                        |       |        |       |
|     indigest                               |       |        |       |
| ion\...\...\...\.......................... |       |        |       |
+--------------------------------------------+-------+--------+-------+

+---------------------------------------------+----+---+-----+-----+-----+
| **2. Over the [last 2 weeks]{.underline},   | *  |   | **\ | **M | **  |
| how often have you been bothered\           | *\ |   | S   | ore | Nea |
| by any of the following problems?**         | \  |   | eve | t   | rly |
|                                             | N  |   | ral | han | eve |
|                                             | ot |   | day | h   | ry\ |
|                                             | at |   | s** | alf | da  |
|                                             | a  |   |     | the | y** |
|                                             | ll |   |     | day |     |
|                                             | ** |   |     | s** |     |
+---------------------------------------------+----+---+-----+-----+-----+
| a.  Little interest or pleasure in doing    |    |   |     |     |     |
|     things\...\...................          |    |   |     |     |     |
+---------------------------------------------+----+---+-----+-----+-----+
| b.  Feeling down, depressed, or             |    |   |     |     |     |
|     hopeless........................        |    |   |     |     |     |
+---------------------------------------------+----+---+-----+-----+-----+
| c.  Trouble falling or staying asleep, or   | *  |   | **\ |     | **\ |
|     sleeping too                            | *\ |   | **  |     | **  |
|     much\...\                               | ** |   |     |     |     |
| ...\...\...\...\...\...\...\...\...\...\... |    |   |     |     |     |
| \...\...\...\...\...................\...... |    |   |     |     |     |
+---------------------------------------------+----+---+-----+-----+-----+
| d.  Feeling tired or having little          |    |   |     |     |     |
|     energy\...\...\.............\.......... |    |   |     |     |     |
+---------------------------------------------+----+---+-----+-----+-----+
| e.  Poor appetite or                        |    |   |     |     |     |
|     overeating\...                          |    |   |     |     |     |
| \...\...\...\...\...\...................... |    |   |     |     |     |
+---------------------------------------------+----+---+-----+-----+-----+
| f.  Feeling bad about yourself --- or that  | *  |   | **\ |     | **\ |
|     you are a failure or have let yourself  | *\ |   | **  |     | **  |
|     or your family                          | ** |   |     |     |     |
|     down........................            |    |   |     |     |     |
+---------------------------------------------+----+---+-----+-----+-----+
| g.  Trouble concentrating on things, such   |    |   | **\ |     | **\ |
|     as reading the newspaper or watching    |    |   | **  |     | **  |
|     television............................. |    |   |     |     |     |
+---------------------------------------------+----+---+-----+-----+-----+
| h.  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\...\...\...\.........             |    |   |     |     |     |
| ........................................... |    |   |     |     |     |
+---------------------------------------------+----+---+-----+-----+-----+
| i.  Thoughts that you would be better off   | *  | * |     |     | **\ |
|     dead or of hurting yourself in some     | *\ | * |     |     | **  |
|     way\...\..                              | ** | \ |     |     |     |
| ........................................... |    | * |     |     |     |
|                                             |    | * |     |     |     |
+---------------------------------------------+----+---+-----+-----+-----+

FOR OFFICE CODING: Som Dis if at least 3 of #1a-m are "a lot" and lack
an adequate biol explanation.\
Maj Dep Syn if answers to #2a or b and five or more of #2a-i are at
least "More than half the days" (count #2i if present at all).\
Other Dep Syn if #2a or b and two, three, or four of #2a-i are at least
"More than half the days" (count #2i if present at all). 1

+-------------------------------------------------+---------+---------+
| **3. Questions about anxiety.**                 | **NO\   | **YES\  |
|                                                 | **      | **      |
| a.  In the [last 4 weeks]{.underline}, have you |         |         |
|     had an anxiety attack  suddenly feeling    |         |         |
|     fear or                                     |         |         |
|                                                 |         |         |
|    panic?...................................... |         |         |
|                                                 |         |         |
| **If you checked "NO", go to question #5.**     |         |         |
+-------------------------------------------------+---------+---------+
| b.  Has this ever happened                      |         |         |
|     before?...........................          |         |         |
+-------------------------------------------------+---------+---------+
| c.  Do some of these attacks come [suddenly out | **\     | **\     |
|     of the blue]{.underline}  that is, in      | \       | \       |
|     situations where you don't expect to be     | **      | **      |
|     nervous or                                  |         |         |
|     uncomfortable?..........                    |         |         |
| ............................................... |         |         |
+-------------------------------------------------+---------+---------+
| d.  Do these attacks bother you a lot or are    | **\     | **\     |
|     you worried about having another            | **      | ****\   |
|     attack?.                                    |         | **      |
| ............................................... |         |         |
+-------------------------------------------------+---------+---------+
| **4. Think about your last bad anxiety          | **NO**  | **YES** |
| attack**.                                       |         |         |
+-------------------------------------------------+---------+---------+
| a.  Were you short of                           |         |         |
|     br                                          |         |         |
| eath?.......................................... |         |         |
+-------------------------------------------------+---------+---------+
| b.  Did your heart race, pound, or              |         |         |
|     skip?...........................\...        |         |         |
+-------------------------------------------------+---------+---------+
| c.  Did you have chest pain or                  |         |         |
|     pressure?............................       |         |         |
+-------------------------------------------------+---------+---------+
| d.  Did you                                     |         |         |
|     sweat?..........                            |         |         |
| ............................................... |         |         |
+-------------------------------------------------+---------+---------+
| e.  Did you feel as if you were                 |         |         |
|     choking?.............................       |         |         |
+-------------------------------------------------+---------+---------+
| f.  Did you have hot flashes or                 |         |         |
|     chills?...............................      |         |         |
+-------------------------------------------------+---------+---------+
| g.  Did you have nausea or an upset stomach, or | **\     | **\     |
|     the feeling that you were going to have     | **      | **      |
|     diarrhea?...........................        |         |         |
+-------------------------------------------------+---------+---------+
| h.  Did you feel dizzy, unsteady, or            |         |         |
|     faint?............................          |         |         |
+-------------------------------------------------+---------+---------+
| i.  Did you have tingling or numbness in parts  |         |         |
|     of your body?...                            |         |         |
+-------------------------------------------------+---------+---------+
| j.  Did you tremble or                          |         |         |
|     sh                                          |         |         |
| ake?........................................... |         |         |
+-------------------------------------------------+---------+---------+
| k.  Were you afraid you were                    |         |         |
|     dying?..................................    |         |         |
+-------------------------------------------------+---------+---------+

+---------------------------------------------+-------+-------+-------+
| **5. Over the [last 4 weeks]{.underline},   | **\   | **\   | *     |
| how often have you been bothered by any of  | \     | Se    | *More |
| the following problems?**                   | Not   | veral | than  |
|                                             | at    | d     | half  |
|                                             | all** | ays** | the   |
|                                             |       |       | d     |
|                                             |       |       | ays** |
+---------------------------------------------+-------+-------+-------+
| a.  Feeling nervous, anxious, on edge, or   |       |       |       |
|     worrying a lot about different          |       |       |       |
|     things                                  |       |       |       |
| ........................................... |       |       |       |
|                                             |       |       |       |
| **If you checked "Not at all", go to        |       |       |       |
| question #6.**                              |       |       |       |
+---------------------------------------------+-------+-------+-------+
| b.  Feeling restless so that it is hard to  |       |       |       |
|     sit still...............                |       |       |       |
+---------------------------------------------+-------+-------+-------+
| c.  Getting tired very                      |       |       |       |
|     ea                                      |       |       |       |
| sily....................................... |       |       |       |
+---------------------------------------------+-------+-------+-------+
| d.  Muscle tension, aches, or               |       |       |       |
|     soreness.........................       |       |       |       |
+---------------------------------------------+-------+-------+-------+
| e.  Trouble falling asleep or staying       |       |       |       |
|     asleep...................               |       |       |       |
+---------------------------------------------+-------+-------+-------+
| f.  Trouble concentrating on things, such   |       |       |       |
|     as reading a book or watching           |       |       |       |
|     TV.                                     |       |       |       |
| ........................................... |       |       |       |
+---------------------------------------------+-------+-------+-------+
| g.  Becoming easily annoyed or              |       |       |       |
|     irritable.......................        |       |       |       |
+---------------------------------------------+-------+-------+-------+
|                                             |       |       |       |
+---------------------------------------------+-------+-------+-------+

FOR OFFICE CODING: Pan Syn if all of #3a-d are 'YES' and four or more of
#4a-k are 'YES'.\
Other Anx Syn if #5a and answers to three or more of #5b-g are "More
than half the days".

+-------------------------------------------+----+---+---+-----+---+-----+
| **6. Questions about eating.**            |    |   | * |     | * |     |
|                                           |    |   | * |     | * |     |
| a.  Do you often feel that you can't      |    |   | \ |     | \ |     |
|     control [what]{.underline} or [how    |    |   | N |     | Y |     |
|     much]{.underline} you                 |    |   | O |     | E |     |
|     eat?..........................        |    |   | \ |     | S |     |
| ......................................... |    |   | * |     | \ |     |
|                                           |    |   | * |     | * |     |
|                                           |    |   |   |     | * |     |
+-------------------------------------------+----+---+---+-----+---+-----+
| b.  Do you often eat, [within any 2-hour  |    |   | * |     | * |     |
|     period]{.underline}, what most people |    |   | * |     | * |     |
|     would regard as an unusually          |    |   | \ |     | \ |     |
|     [large]{.underline} amount of         |    |   | \ |     | \ |     |
|     food?.............................    |    |   | * |     | * |     |
| ......................................... |    |   | * |     | * |     |
|                                           |    |   |   |     |   |     |
| **If you checked 'NO' to either #a or #b, |    |   |   |     |   |     |
| go to question #9.**                      |    |   |   |     |   |     |
+-------------------------------------------+----+---+---+-----+---+-----+
| c.  Has this been as often, on average,   |    |   | * |     | * |     |
|     as twice a week for the last 3        |    |   | * |     | * |     |
|     months?                               |    |   | \ |     | \ |     |
|     ..................                    |    |   | * |     | * |     |
| ......................................... |    |   | * |     | * |     |
+-------------------------------------------+----+---+---+-----+---+-----+
| **7. In the last 3 months have you        | *  | * |   |     |   |     |
| [often]{.underline} done any of the       | *\ | * |   |     |   |     |
| following in order to avoid gaining       | NO | \ |   |     |   |     |
| weight ?**                                | ** | Y |   |     |   |     |
|                                           |    | E |   |     |   |     |
|                                           |    | S |   |     |   |     |
|                                           |    | * |   |     |   |     |
|                                           |    | * |   |     |   |     |
+-------------------------------------------+----+---+---+-----+---+-----+
| a.  Made yourself vomit?                  |    |   |   |     |   |     |
|     ...................................   |    |   |   |     |   |     |
+-------------------------------------------+----+---+---+-----+---+-----+
| b.  Took more than twice the recommended  | *  | * |   |     |   |     |
|     dose of                               | *\ | * |   |     |   |     |
|     laxatives?..........                  | ** | \ |   |     |   |     |
| ......................................... |    | * |   |     |   |     |
|                                           |    | * |   |     |   |     |
+-------------------------------------------+----+---+---+-----+---+-----+
| c.  Fasted  not eaten anything at all    | *  | * |   |     |   |     |
|     for at least 24                       | *\ | * |   |     |   |     |
|     hours?................                | ** | \ |   |     |   |     |
| ......................................... |    | * |   |     |   |     |
|                                           |    | * |   |     |   |     |
+-------------------------------------------+----+---+---+-----+---+-----+
| d.  Exercised for more than an hour       | *  | * |   |     |   |     |
|     specifically to avoid gaining weight  | *\ | * |   |     |   |     |
|     after binge eating?...                | ** | \ |   |     |   |     |
|                                           |    | * |   |     |   |     |
|                                           |    | * |   |     |   |     |
+-------------------------------------------+----+---+---+-----+---+-----+
| **8. If you checked ' YES' to any of      |    |   | * |     | * |     |
| these ways of avoiding gaining weight,    |    |   | * |     | * |     |
| were any as often, on average, as twice a |    |   | N |     | Y |     |
| week?...............**                    |    |   | O |     | E |     |
|                                           |    |   | \ |     | S |     |
|                                           |    |   | * |     | \ |     |
|                                           |    |   | * |     | * |     |
|                                           |    |   |   |     | * |     |
+-------------------------------------------+----+---+---+-----+---+-----+

+-------------------------------------------------+---------+---------+
| 9\. **Do you ever drink alcohol (including beer | **NO\   | **YES\  |
| or wine)?**.....................                | **      | **      |
|                                                 |         |         |
| **If you checked "NO" go to question #11.**     |         |         |
+-------------------------------------------------+---------+---------+
| **10. Have any of the following happened to     | **\     | **\     |
| you\                                            | NO**    | YES**   |
| [more than once in the last 6                   |         |         |
| months]{.underline}?**                          |         |         |
+-------------------------------------------------+---------+---------+
| a.  You drank alcohol even though a doctor      | **\     | **\     |
|     suggested that you stop drinking because of | **      | **      |
|     a problem with your health..........        |         |         |
+-------------------------------------------------+---------+---------+
| b.  You drank alcohol, were high from alcohol,  | **\     | **\     |
|     or hung over while you were working, going  | \       | \       |
|     to school, or taking care of children or    | **      | **      |
|     other                                       |         |         |
|     resp                                        |         |         |
| onsibilities................................... |         |         |
+-------------------------------------------------+---------+---------+
| c.  You missed or were late for work, school,   | **\     | **\     |
|     or other activities because you were        | **      | **      |
|     drinking or hung                            |         |         |
|     over.........................               |         |         |
+-------------------------------------------------+---------+---------+
| d.  You had a problem getting along with other  | **\     | **\     |
|     people while you were                       | **      | **      |
|     drinking.............                       |         |         |
| ............................................... |         |         |
+-------------------------------------------------+---------+---------+
| e.  You drove a car after having several drinks | **\     | **\     |
|     or after drinking too                       | **      | **      |
|     much..................                      |         |         |
| ............................................... |         |         |
+-------------------------------------------------+---------+---------+

**11. If you checked off [any]{.underline} problems on this
questionnaire, how [difficult]{.underline} 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\ **Somewhat\        **Very\            **Extremely\
  at all**         difficult**        difficult**        difficult**

                                                         
  ---------------- ------------------ ------------------ ------------------

FOR OFFICE CODING: Bul Ner if #6a,b, and-c and #8 are all 'YES'; Bin Eat
Dis the same but #8 either 'NO' or left blank.\
Alc Abu if any of #10a-e is 'YES'.

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke
and colleagues, with an educational grant from Pfizer Inc.\
For research information, contact Dr. Spitzer at <rls8@columbia.edu>.\
The names PRIME-MD® and PRIME-MD TODAY® are trademarks of Pfizer Inc. 3

**During the [past 4 weeks]{.underline}, how much have you been**

**bothered by any of the following problems?**

**Not**

**bothered Bothered Bothered**

**at all a little a lot**

a\. Stomach pain ...................................................

b\. Back pain ........................................................

c\. Pain in your arms, legs, or joints (knees, hips, etc.) ..

her problems with your

periods \[***Women only***\] .....................................

e\. Headaches ......................................................

.......................................

g\. Dizziness .........................................................

..............................................

i\. Feeling your heart pound or race ..........................

....................................

............

l\. Constipation, loose bowels, or diarrhea ..................

igestion .................................

n\. Feeling tired or having low energy .........................

.........................................

Nine Symptom Checklist (PHQ-9)

+---------------------------------------------+-----+---+-----+-----+-----+
| **Over the [last 2 weeks]{.underline}, how  | **\ | * |     | **M | **\ |
| often have you been bothered by any of the  | \   | * |     | ore | Nea |
| following problems?**                       | Not | \ |     | t   | rly |
|                                             | at  | \ |     | han | eve |
|                                             | al  | S |     | h   | ry\ |
|                                             | l** | e |     | alf | da  |
|                                             |     | v |     | the | y** |
|                                             |     | e |     | day |     |
|                                             |     | r |     | s** |     |
|                                             |     | a |     |     |     |
|                                             |     | l |     |     |     |
|                                             |     | d |     |     |     |
|                                             |     | a |     |     |     |
|                                             |     | y |     |     |     |
|                                             |     | s |     |     |     |
|                                             |     | * |     |     |     |
|                                             |     | * |     |     |     |
+---------------------------------------------+-----+---+-----+-----+-----+
| > 1\. Little interest or pleasure in doing  | 0   | 1 |     | 2   | 3   |
| > things\...\.............                  |     |   |     |     |     |
+---------------------------------------------+-----+---+-----+-----+-----+
| > 2\. Feeling down, depressed, or           | 0   | 1 |     | 2   | 3   |
| > hopeless..................                |     |   |     |     |     |
+---------------------------------------------+-----+---+-----+-----+-----+
| > 3\. Trouble falling or staying asleep, or | 0   | 1 |     | 2   | 3   |
| > sleeping too                              |     |   |     |     |     |
| > muc                                       |     |   |     |     |     |
| h\...\...\...\...\...\...\...\...\...\...\. |     |   |     |     |     |
| ..\...\...\...\...\........................ |     |   |     |     |     |
+---------------------------------------------+-----+---+-----+-----+-----+
| > 4\. Feeling tired or having little        | 0   | 1 |     | 2   | 3   |
| > energy\...\.........\............         |     |   |     |     |     |
+---------------------------------------------+-----+---+-----+-----+-----+
| > 5\. Poor appetite or                      | 0   | 1 |     | 2   | 3   |
| > overeating                                |     |   |     |     |     |
| \...\...\...\...\...\...\.................. |     |   |     |     |     |
+---------------------------------------------+-----+---+-----+-----+-----+
| > 6\. Feeling bad about yourself --- or     | 0   | 1 |     | 2   | 3   |
| > that you are a failure or have let        |     |   |     |     |     |
| > yourself or your family down......        |     |   |     |     |     |
+---------------------------------------------+-----+---+-----+-----+-----+
| > 7\. Trouble concentrating on things, such | 0   | 1 |     | 2   | 3   |
| > as reading the newspaper or watching      |     |   |     |     |     |
| > television..................              |     |   |     |     |     |
+---------------------------------------------+-----+---+-----+-----+-----+
| > 8\. Moving or speaking so slowly that     | 0   | 1 |     | 2   | 3   |
| > 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 | 0   |   | 1   | 2   | 3   |
| > dead or of hurting yourself in some       |     |   |     |     |     |
| > way\...\..........................        |     |   |     |     |     |
+---------------------------------------------+-----+---+-----+-----+-----+

**(*For office coding: Total Score \_\_\_\_\_ =* \_\_\_ + \_\_\_ +
\_\_\_ )\
**

**If you checked off [any]{.underline} problems, how
[difficult]{.underline} 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\ **Somewhat\        **Very\            **Extremely\
  at all**         difficult**        difficult**        difficult**

                                                         
  ---------------- ------------------ ------------------ ------------------

From the Primary Care Evaluation of Mental Disorders Patient Health
Questionnaire (PRIME-MD PHQ). The PHQ was developed by Drs. Robert L.
Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues. For research
information, contact Dr. Spitzer at <rls8@columbia.edu>. PRIME-MD® is a
trademark of Pfizer Inc. Copyright© 1999 Pfizer Inc. All rights
reserved. Reproduced with permission.