RESET FORM

SUCCEED Mental Health Questionnaire

Patient identifier: __________________________________ Date: ___________________

PHQ-9

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

More than Nearly

Not at all Several half the every day
(0) days (1) days (2) (3)

1. Little interest or pleasure in doing things.    

2. Feeling down, depressed, or hopeless.    

3. Trouble falling/staying asleep, sleeping too much.    

4. Feeling tired or having little energy.    

5. Poor appetite or overeating.    

6. Feeling bad about yourself, or that you are a

   
failure, or have let yourself or your family down.

7. Trouble concentrating on things, such as reading

   
the newspaper or watching TV.

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 more than usual.

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

   
hurting yourself in some way.

2. If you checked off any problem on this questionnaire so far, 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?

 Not difficult  Somewhat  Very  Extremely

at all difficult difficult difficult

0
TOTAL SCORE _________________

PHQ9 Copyright © Pfizer Inc. All rights reserved. Reproduced with permission.
PRIME-MD ® is a trademark of Pfizer Inc.
 GAD-7

Not Several More Nearly

Over the last two weeks, how often have you at all days than half every
been bothered by the following problems? (0) (1) the days day
(2) (3)
1. Feeling nervous, anxious, or on edge
0 1 2 3
2. Not being able to stop or control worrying
0 1 2 3
3. Worrying too much about different things
0 1 2 3
4. Trouble relaxing
0 1 2 3
5. Being so restless that it is hard to sit still
0 1 2 3
6. Becoming easily annoyed or irritable
0 1 2 3
7. Feeling afraid, as if something awful
might happen 0 1 2 3

0
Total score _______

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

Not difficult at all Somewhat difficult Very difficult Extremely difficult

□ □ □ □
Source: 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 ris8@columbia.edu. PRIME-MD® is a trademark of Pfizer Inc. Copyright© 1999 Pfizer Inc. All rights reserved.
Reproduced with permission
 PCL-5
Instructions: Below is a list of problems that people sometimes have in response to a very stressful
experience. Please read each problem carefully and then select one of the numbers to the right to indicate
how much you have been bothered by that problem in the past month.
Not at A little Moderately Quite a Extremely
In the past month, how much were you bothered by: all (0) bit (1) (2) bit (3) (4)
1. Repeated, disturbing, and unwanted memories of the
0 1 2 3 4
stressful experience?
2. Repeated, disturbing dreams of the stressful experience? 0 1 2 3 4
3. Suddenly feeling or acting as if the stressful experience were
actually happening again (as if you were actually back there 0 1 2 3 4
reliving it)?
4. Feeling very upset when something reminded you of the
0 1 2 3 4
stressful experience?
5. Having strong physical reactions when something reminded
you of the stressful experience (for example, heart pounding, 0 1 2 3 4
trouble breathing, sweating)?
6. Avoiding memories, thoughts, or feelings related to the
0 1 2 3 4
stressful experience?
7. Avoiding external reminders of the stressful experience (for
example, people, places, conversations, activities, objects, or 0 1 2 3 4
situations)?
8. Trouble remembering important parts of the stressful
0 1 2 3 4
experience?
9. Having strong negative beliefs about yourself, other people,
or the world (for example, having thoughts such as: I am 0 1 2 3 4
bad, there is something seriously wrong with me, no one can
be trusted, the world is completely dangerous)?
10. Blaming yourself or someone else for the stressful
0 1 2 3 4
experience or what happened after it?
11. Having strong negative feelings such as fear, horror, anger,
0 1 2 3 4
guilt, or shame?
12. Loss of interest in activities that you used to enjoy? 0 1 2 3 4
13. Feeling distant or cut off from other people? 0 1 2 3 4
14. Trouble experiencing positive feelings (for example, being
unable to feel happiness or have loving feelings for people 0 1 2 3 4
close to you)?
15. Irritable behaviour, angry outbursts, or acting aggressively? 0 1 2 3 4
16. Taking too many risks or doing things that could cause you
0 1 2 3 4
harm?
17. Being “superalert” or watchful or on guard? 0 1 2 3 4
18. Feeling jumpy or easily startled? 0 1 2 3 4
19. Having difficulty concentrating? 0 1 2 3 4
20. Trouble falling or staying asleep? 0 1 2 3 4

0
Score total: ___________

PCL-5 (8/14/2013) Weathers, Litz, Keane, Palmieri, Marx, & Schnurr -- National Center for PTSD