Patient Health Questionnaire Form Template
Screen for health conditions efficiently, with a questionnaire patients actually complete.
Patient health questionnaires are essential clinical tools. Used to screen for depression, anxiety, and other conditions that patients might not bring up on their own. But when they're administered on a clipboard in a crowded waiting room, patients rush through them, underreport symptoms, or skip the questionnaire entirely. The screening only works if the answers are honest and the form is actually completed.
This patient health questionnaire form template presents validated screening questions in Typeform's private, one-question-at-a-time format. Creating a more reflective, less rushed experience. Patients answer each item thoughtfully, without the pressure of a nurse watching over their shoulder or other patients sitting nearby. Conditional logic can adapt follow-up questions based on symptom severity, diving deeper when initial responses indicate a concern.
Send the link before appointments, embed it in your patient portal, or share it via secure messaging. Responses connect to your EHR or clinical tools through integrations. Giving providers a scored, organized snapshot of patient health before the visit even begins.
A patient health questionnaire (PHQ) is a standardized screening instrument used to assess mental health conditions. Most commonly depression and anxiety. The PHQ-9 (for depression) and GAD-7 (for anxiety) are among the most widely used versions. These tools use validated question sets with scored responses to identify symptoms and their severity, guiding clinical decision-making.
Digital administration improves honesty, completion rates, and clinical utility. Patients report more accurate symptom information when answering privately on a screen than on paper in a public waiting room. Auto-scoring eliminates calculation errors. And digital responses integrate directly with clinical systems, reducing the gap between screening and clinical action.
- PHQ-9 items: frequency of depressive symptoms over the past 2 weeks
- GAD-7 items: frequency of anxiety symptoms over the past 2 weeks
- Functional impairment question (how much symptoms affect daily life)
- Sleep quality and changes in appetite
- Physical symptoms (fatigue, pain, headaches)
- Safety screening (thoughts of self-harm — with appropriate clinical protocols)
Standard PHQ instruments use a 4-point scale (0-3) for each item: "not at all," "several days," "more than half the days," and "nearly every day." Scores are summed to produce a total that maps to severity categories — minimal, mild, moderate, moderately severe, and severe. Typeform's scoring feature can calculate this automatically and display the result to the provider (not necessarily the patient).
A positive screening is a clinical flag, not a diagnosis. High scores should trigger a follow-up conversation with the patient, a more thorough clinical assessment, and appropriate referrals as indicated. Build your clinical workflow so that flagged responses generate immediate alerts to the reviewing provider — don't let high-risk screenings sit unreviewed. For responses indicating immediate safety concerns, ensure your protocol includes direct outreach and crisis resources.
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