Paarl Patient Forms – PHQ-9 / GAD-7 Form Initial

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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

A copy of your results will be emailed to KetaMIND Clinics South Africa. Should your score indicate you are severely depressed, we may contact you to discuss available treatment options, including but not limited to KCSA Infusion Therapy.

This form is to be filled in prior to coming in for treatment.

    Over the past two 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 asleep, staying asleep, or sleeping to much

    4.Feeling tired or having little energy

    5.Poor appetite or overeating

    6.Feeling bad about yourself - or that you're a failure or have to 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

    10.If you checked off any problems, how difficult have those problems made it for you to do your work, take care of things at home, or get along with other people?

    Not difficult at allSomewhat difficultVery difficultExtremely difficult

    Total scores

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

    GAD-7 score