Bedfordview(GP) Bryanston(GP) Hillcrest(KZN) PMB(KZN) Umhlanga(KZN) Ballito(KZN) Constantia(WC) Paarl(WC) Kimberley(NC)
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Kimberley Patient Forms – PHQ-9 / GAD-7 During Therapy

Home / Patient Forms / Kimberley Patient Forms – PHQ-9 / GAD-7 During Therapy

This form is strictly confidential and is encrypted with a SSL certificate on a secure server. We never share your information with any third parties. Alternatively you can download a copy of the form and submit it to adminkimberly@ketamind.co.za

A copy of your results with be emailed to KetaMIND Clinics South Africa.

Fill in this form the morning after each infusion.

    PHQ-9 Questions:

    Over the past two weeks, how often have you been bothered by the following problems?

    1. Little interest or pleasure in doing things

    0123

    2. Feeling down, depressed or hopeless

    0123

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

    0123

    4. Feeling tired or having little energy

    0123

    5. Poor appetite or overeating

    0123

    6. Feeling bad about yourself

    0123

    7. Trouble concentrating on things

    0123

    8. Moving or speaking slowly, or being very fidgety or restless

    0123

    9. Thoughts that you would be better off dead or of hurting yourself

    0123

    Total PHQ-9 Score:

    GAD-7 Questions:

    Over the last 2 weeks, how often have you been bothered by the following problems?

    1. Feeling nervous, anxious or on edge

    0123

    2. Not being able to stop or control worrying

    0123

    3. Worrying too much about different things

    0123

    4. Trouble relaxing

    0123

    5. Being so restless that it’s hard to sit still

    0123

    6. Becoming easily annoyed or irritable

    0123

    7. Feeling afraid as if something awful might happen

    0123

    Total GAD-7 Score (out of 21):