Dr. Jeffrey Soley

Sports and Functional Medicine for Healthy Living

Patient Health Questionnaire

Fields marked with an * are required

1. Describe your symptoms

2. How often do you experience your symptoms?

3. What describes the nature of your symptoms?

4. How are your symptoms changing?

5. During the past 4 weeks:

6. During the past 4 weeks how much of the time has your condition interfered with your social activities?

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

8. Who have you seen for your symptoms?

9. Have you had similar symptoms in the past?

10. What is your occupation?