This questionnaire is an important part of providing you with the best health care possible. Your answers will help in understanding problems that you may have. Please answer every question to the best of your ability.
0= Not bothered‚ 1= Bothered a little‚ 3= Bothered a lot
- During the last4weeks‚ how much have you been bothered by any of the following problems?
| 1. Stomach pain……………………………………………….. | 1 | 2 | 3 |
| 2. Back pain……………………………….….……………….. | |||
| 3. Pain in your arms‚ legs‚ or joints (knees‚ hips‚ etc.)……. | |||
| 4. Feeling tired or having little energy…………..………… | |||
| 5. Trouble falling or staying asleep‚ or sleeping too much …………… | |||
| 6. Menstrual cramps or other problems with your periods ……(women only) | |||
| 7. Pain or problems during sexual intercourse…………. | |||
| 8. Headaches…………………………………..………………. | |||
| 9. Chest pain………………………………….………………… | |||
| 10. Dizziness..…………………………………..……………….
|
|||
| 11. Fainting spells…………………………….………………… | |||
| 12. Feeling your heart pound or race….…………………… | |||
| 13. 13. Shortness of breath…………………..…………………… | |||
| 14. Constipation‚ loose bowels‚ or diarrhea……………… | |||
| 15. Nausea‚ gas‚ or indigestion…………..………………… |
http://www.healthplus-ny.org/data/bh_phq.pdf
http://www.goodmedicine.org.uk