Dr. Jeffrey Soley
Sports and Functional Medicine for Healthy Living
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Patient Health Questionnaire
If you are a human and are seeing this field, please leave it blank.
Fields marked with an
*
are required
First Name
*
Last Name
*
1. Describe your symptoms
Describe your symptoms
When did your symptoms start?
How did your symptoms begin?
2. How often do you experience your symptoms?
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?
What describes the nature of your symptoms?
Sharp
Dull Ache
Numb
Shooting
Burning
Tingling
4. How are your symptoms changing?
How are your symptoms changing?
Getting Better
Not Changing
Getting Worse
5. During the past 4 weeks:
a. Indicate the average intensity of your symptoms
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...
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?
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?
XRays
MRI
CT Scan
Other
When were they performed?
9. Have you had similar symptoms in the past?
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?
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
Home
Our Practice
Services Offered
Schedule Your Appointment
New Patient Paperwork
Patient Testimonials
Patient Resources
Recommended Viewing
Chiropractic