Dr. Jeffrey Soley
Sports and Functional Medicine for Healthy Living
Patient Health Questionnaire
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Fields marked with an
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?
4. How are your symptoms changing?
How are your symptoms changing?
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
Quite a bit
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...
8. Who have you seen for your symptoms?
Who have you seen for your symptoms?
a. What treatment did you receive and when?
b. What tests have you had for your symptoms?
When were they performed?
9. Have you had similar symptoms in the past?
Have you had similar symptoms in the past?
a. If you have received treatment in the past for the same or similar symptoms, who did you see?
10. What is your occupation?
What is your occupation?
a. If you are not retired, a homemaker, or a student, what is your current work status?