Form Phq-Patient Health Questionnaire Form Page 2
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1
2Patient Name:
DOB:
Date:
11. During the past 4 weeks how much of the time has your condition interfered with your social activities?
(Example: visiting with friends, relatives, etc.)
(Check one below)
___ All the time ___Most of the time ___Some of the time ___ A little of the time ___ None of the time
12. In general would you say your overall health right now is… (Check one below)
___ Excellent
___Very Good
___ Good
___ Fair
___ Poor
13. Who have you seen for your symptoms? (Check one below)
___ No One ___ Chiropractor ___ Medical Doctor ___ Physical Therapist ___ Other ______________________
What treatment did you receive and when?
14. What tests have you had for your symptoms and when were they performed? (Check one below)
____ X-rays date:
____CT Scan
date:
____ MRI date:
____Other
date:
Did you have surgery? ___ Yes ___No
Date of Surgery if applicable: ____/____/____
15. Have you had similar symptoms in the past? ___ Yes ___ No
If you have received treatment in the past for the same similar symptoms, who did you see? (Check one below)
___ No One ___ Chiropractor ___ Medical Doctor ___ Physical Therapist ___ Other ______________________
16. What is your occupation? ___ Professional/Executive
___ Laborer
___ Retired
(Check all that apply)
___ White Collar/Secretarial
___ Homemaker
___ Tradesperson
___ FT Student
___ Other __________________
a) If you are not retired, a homemaker, or a student, what is your current work status? (Check all that apply)
___ FT
___ PT
___Self-Employed
___ Unemployed
___ Off Work
___ Other
Please check off if you have had any of the conditions listed below:
____
High blood pressure
____
Epilepsy
____
Angina
____
Diabetes
____
Heart attack
____
Rheumatoid Arthritis
____
Stroke
____
Arthritis
____
Asthma
____
Pregnancy
____
HIV/AIDS
____
Other
____
Tumor
____
Tobacco
packs/day ____
____
Systemic Lupus
____
Drug or Alcohol Dependence
____
Hepatitis
____
Coffee/Tea/Caffeine drinks: cups/cans per day ____
____
Cancer Location:
Date: ___/___/___
Present: Weight
Height: Feet_____ Inches _____
Hospitalization/Surgical Procedures (list if not described elsewhere):
Medications:
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Parent category: Life