Form Phq-Patient Health Questionnaire Form
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1
2PATIENT HEALTH QUESTIONNAIRE – PHQ
(All Questions Must Be Answered)
Patient Name:
DOB:
Date:
1. When did your symptoms start? ___/___/___
2. Describe your symptoms:
3. What is your goal for therapy?
4. How often do you experience your symptoms?
___ Constantly (76%-100% of the day)
Indicate where you have pain or other symptoms:
___ Frequently (51%-75% of the day)
(MARK PICTURE WHERE YOU HAVE PAIN)
___ Occasionally (26%-50% of the day)
___ Intermittently (0%-25% of the day)
5. What describes the nature of your symptoms?
(Check all that apply)
___ Sharp
___ Shooting
___ Dull Ache
___ Burning
___ Numb
___ Tingling
6. How are your symptoms changing?
(Check one below)
___ Getting better
___ Not changing
___ Getting worse
7. Your symptoms are worse in the:
___ Morning
___ Increased during the day
___ Afternoon
___ Night
___ Same all day
What movement causes the pain to increase?
During the past 4 weeks: (Circle to indicate)
Indicate the intensity of pain at rest: No Pain 0 1 2 3 4 5 6 7 8 9 10 Unbearable Pain
Indicate the intensity of pain with movement: No Pain 0 1 2 3 4 5 6 7 8 9 10 Unbearable Pain
8. How much has it interfered with your normal work (including home and housework)? (Check one below)
___ None of the time ___ A little bit ___ Moderately ___ Quite a bit ___ Extremely
9. What makes your problem better?
___ Nothing
___ Standing
___ Movement/Exercise
(Check all that apply)
___ Lying Down
___ Sitting
___ Inactivity
10. What makes your problem worse?
___ Nothing
___ Standing
___ Movement/Exercise
(Check all that apply)
___ Lying Down
___ Sitting
___ Inactivity
(1 of 2)
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Parent category: Life