Patient Health Questionnaire

Patient Name

Date

1. Describe your symptoms

a. When did your symptoms start?

b. How did your symptoms begin?

2. How often do you experience your symptoms?

Constantly (76-100% of the day) Frequently (51-75% of the day) Occasionally (26-50% of the day) Intermittently (0-25% of the day)

Indicate where you have pain or other symptoms

3. What describes the nature of your symptoms?

Sharp

Dull ache

Numb

Shooting

Burning

Tingling

4. How are your symptoms changing?

Getting Better Not Changing Getting Worse

5. During the past 4 weeks:

b. How much has pain interfered with your normal work (including both work outside the home, and housework)

Not at all A little bit Moderately Quite a bit Extremely

6. During the past 4 weeks how much of the time has your condition interfered with your social activities? (like visiting with friends, relatives, etc)

All of the time Most of the time Some of the time A little of the time None of the time

7. In general would you say your overall health right now is...

Excellent Very Good Good Fair Poor

8. Who have you seen for your symptoms?

No One Chiropractor Medical Doctor Physical Therapist Other

a. What treatment did you receive and when?

b. What tests have you had for your symptoms and when were they performed?

Xrays

MRI

CT Scan

Other

If other, please specify.

Indicate date

9. Have you had similar symptoms in the past?

Yes No

a. If you have received treatment in the past for the same or similar symptoms, who did you see?

This Office Chiropractor Medical Doctor Physical Therapist Other

10. What is your occupation?

Professional/Executive White Collar/Secretarial Tradesperson Laborer Homemaker FT Student Retired Other

a. If you are not retired, a homemaker, or a student, what is your current work status?

Full-time Part-time Self-employed Unemployed Off work Other

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Patient Signature

Date

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Patient Health Questionnaire - PHQ