Appendix 3

Master of Family Medicine Project 2005

 
To validate a Chinese Version of PHQ-9
 
Demographic Data of Patient:
 
Clinic Name:       Date:      
Patient's Name/Clinic Number: Sex: Male/Female
Date of Birth: Marital Status: Single/Married/Divorced/Widowed
Education level: Primary/Secondary/Tertiary  
   
Medical History:  
Current Medication:  
History of Substance Abuse:  
History of Psychiatric Illness:  
Other Major Illness:  
Recent Bereavement:  
Family History:  
Psychiatric Illness:  
   
Social History:  
Smoking:   cigarettes per day   Alcohol:   units per week