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

Home / Patient Forms / Umhlanga Patient Forms – PHQ-9 / GAD-7 Form Initial

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  [email protected].

A copy of your results with 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.

    PHQ9 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

    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?

    0123

    Total PHQ-9 Score:

    GAD7 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:



      Tell us about your experience!

      We strive for high levels of patient care, we would really value your feedback on the bad experience you had

        Tell us about your experience!

        We strive for high levels of patient care, we would really value your feedback on the bad experience you had

          Tell us about your experience!

          We strive for high levels of patient care, we would really value your feedback on the bad experience you had

            Tell us about your experience!

            We strive for high levels of patient care, we would really value your feedback on the bad experience you had

              Tell us about your experience!

              We strive for high levels of patient care, we would really value your feedback on the bad experience you had

                Tell us about your experience!

                We strive for high levels of patient care, we would really value your feedback on the bad experience you had