This screening test comprises four sentences: each represents a symptom.

Ask the patient:
How often have you been bothered by any of the following problems over the last 2 weeks?

1. Feeling nervous, anxious, or tense
2. Not being able to stop or control worrying
3. Have little interest or pleasure in doing things
4. Feeling down, depressed, or hopeless

Each problem has four possible answers:
Not at all = 0
Several days = 1
More than half of the days = 2
Nearly every day = 3

Total scores
0 - 2 = none
3 - 5 = mild
6 - 8 = moderate
9 - 12 = severe

Anxiety subscale = items 1 + 2 (score range: 0 to 6)
Depression subscale = items 3 + 4 (score range: 0 to 6)

On each subscale, a score of 3 or more is considered positive for screening purposes.

See reference for more information.

Adapted from Tools and Resources. Center to Advance Palliative Care (CAPC). Anxiety and depression: PHQ-4 screening tool. Internet. Available at https://www.capc.org/documents/download/467/. Accessed on October 15, 2021.