Locations Phone

Canton - PHONE: (734) 737-1200
Taylor - PHONE: (734) 285-8282
Brighton - PHONE: (810) 220-2787
Clarkston - PHONE: (248) 922-2300
Southfield - PHONE: (248) 213-0501
St Clair Shores - PHONE: (586) 777-9000

Patient Health Questionnaire

If you’ve just requested an appointment, please take a moment to fill out our patient health questionnaire. Filling this out will help us better serve you at your appointment.

Patient Health Questionnaire
  • Over the last 2 weeks, how often have you been bothered by any of the following problems?
    0
  • Ratings*Not at allSeveral daysMore than half the daysNearly every day
    Little interest or pleasure in doing things
    Feeling down, depressed, or hopeless
    Trouble falling or staying asleep, or sleeping too much Timeliness
    Feeling tired or having little energy
    Poor appetite or overeating
    Poor appetite or overeating
    Trouble concentrating on things, such as reading the newspaper or watching television
    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
    Thoughts that you would be better off dead or of hurting yourself in some way
    1
  • If you checked off any problems, 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 at all
    Somewhat difficult
    Very difficult
    Extremely difficult
    2
  • Name*full name
    3
  • Phone*best contact number
    4
  • Email*a valid email address
    5
  • Did you recently request an appointment?*you may have been redirected to this page after requesting an appointment
    Yes
    No
    6
  • 7
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