Patient health questionnaire (PHQ)

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 unless you are requested to skip over a question.
Name:	Age:	Sex: [ ] Female [ ] Male		Date:
1. During the last 4 weeks, how much have you been bothered by any of the following problems?	Not bothered at all		Bothered a little	Bothered a lot
a. Stomach pain	[ ]		[ ]	[ ]
b. Back pain	[ ]		[ ]	[ ]
c. Pain in your arms, legs, or joints (knees, hips, etc)	[ ]		[ ]	[ ]
d. Menstrual cramps or other problems with your periods	[ ]		[ ]	[ ]
e. Pain or problems during sexual intercourse	[ ]		[ ]	[ ]
f. Headaches	[ ]		[ ]	[ ]
g. Chest pain	[ ]		[ ]	[ ]
h. Dizziness	[ ]		[ ]	[ ]
i. Fainting spells	[ ]		[ ]	[ ]
j. Feeling your heart pound or race	[ ]		[ ]	[ ]
k. Shortness of breath	[ ]		[ ]	[ ]
l. Constipation, loose bowels, or diarrhea	[ ]		[ ]	[ ]
m. Nausea, gas, or indigestion	[ ]		[ ]	[ ]

2. Over the last 2 weeks, how often have you been bothered by any of the following problems?	Not at all	Several days	More than half the days	Nearly every day
a. Little interest or pleasure in doing things	[ ]	[ ]	[ ]	[ ]
b. Feeling down, depressed, or hopeless	[ ]	[ ]	[ ]	[ ]
c. Trouble falling or staying asleep, or sleeping too much	[ ]	[ ]	[ ]	[ ]
d. Feeling tired or having little energy	[ ]	[ ]	[ ]	[ ]
e. Poor appetite or overeating	[ ]	[ ]	[ ]	[ ]
f. Feeling bad about yourself, or that you are a failure, or have let yourself or your family down	[ ]	[ ]	[ ]	[ ]
g. Trouble concentrating on things, such as reading the newspaper or watching television	[ ]	[ ]	[ ]	[ ]
h. Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual?	[ ]	[ ]	[ ]	[ ]
i. Thoughts that you would be better off dead or of hurting yourself in some way	[ ]	[ ]	[ ]	[ ]

FOR OFFICE CODING: Som Dis if at least three of #1a-m are "a lot" and lack an adequate biol explanation. Maj Dep Syn if answers to #2a or b and five or more of #2a-i are at least "More than half the days" (count #2i if present at all). Other Dep Syn if #2a or b and two, three, or four of #2a-i are at least "More than half the days" (count #2i if present at all).

3. Questions about anxiety			No	Yes
a. In the last 4 weeks, have you had an anxiety attack - suddenly feeling fear or panic?			[ ]	[ ]
If you checked "No", go to question #5
b. Has this ever happened before?			[ ]	[ ]
c. Do some of these attacks come suddenly out of the blue - that is, in situations where you don't expect to be nervous or uncomfortable?			[ ]	[ ]
d. Do these attacks bother you a lot or are you worried about having another attack?			[ ]	[ ]

4. Think about your last bad anxiety attack			No	Yes
a. Were you short of breath?			[ ]	[ ]
b. Did your heart race, pound, or skip?			[ ]	[ ]
c. Did you have chest pain or pressure?			[ ]	[ ]
d. Did you sweat?			[ ]	[ ]
e. Did you feel as if you were choking?			[ ]	[ ]
f. Did you have hot flashes or chills?			[ ]	[ ]
g. Did you have nausea or an upset stomach, or the feeling that you were going to have diarrhea?			[ ]	[ ]
h. Did you feel dizzy, unsteady, or faint?			[ ]	[ ]
i. Did you have tingling or numbness in parts of your body?			[ ]	[ ]
j. Did you tremble or shake?			[ ]	[ ]
k. Were you afraid you were dying?			[ ]	[ ]

5. Over the last 4 weeks, how often have you been bothered by any of the following problems?		Not at all	Several days	More than half the days
a. Feeling nervous, anxious, on edge, or worrying a lot about different things		[ ]	[ ]	[ ]
If you checked "Not at all", go to question #6
b. Feeling restless so that it is hard to sit still		[ ]	[ ]	[ ]
c. Getting tired very easily		[ ]	[ ]	[ ]
d. Muscle tension, aches, or soreness		[ ]	[ ]	[ ]
e. Trouble falling asleep or staying asleep		[ ]	[ ]	[ ]
f. Trouble concentrating on things, such as reading a book, watching television		[ ]	[ ]	[ ]
g. Becoming easily annoyed or irritable		[ ]	[ ]	[ ]

FOR OFFICE CODING: Pan Syn if all of #3a-d are 'YES' and four or more of #4a-k are 'YES'. Other Anx Syn if #5a and answers to three or more of #5b-g are "More than half the days".

6. Questions about eating			No	Yes
a. Do you often feel that you can't control what or how much you eat?			[ ]	[ ]
b. Do you often eat, within any 2-hour period, what most people would regard as an unusually large amount of food?			[ ]	[ ]
If you checked "No" to either #6a or #6b, go to question #9
c. Has this been as often, on average, as twice a week for the last 3 months?			[ ]	[ ]

7. In the last 3 months have you often done any of the following in order to avoid gaining weight?			No	Yes
a. Made yourself vomit?			[ ]	[ ]
b. Took more than twice the recommended dose of laxatives?			[ ]	[ ]
c. Fasted - not eaten anything at all for at least 24 hours?			[ ]	[ ]
d. Exercised for more than an hour specifically to avoid gaining weight after binge eating?			[ ]	[ ]

8. If you checked "Yes" to any of these ways of avoiding gaining weight, were any as often, on average, as twice a week?			No [ ]	Yes [ ]

9. Do you ever drink alcohol (including beer or wine)?			No [ ]	Yes [ ]
If you checked "No", go to question #11

10. Have any of the following happened to you more than once in the last 6 months?			No	Yes
a. You drank alcohol even though a doctor suggested that you stop drinking because of a problem with your health			[ ]	[ ]
b. You drank alcohol, were high from alcohol, or hung over while you were working, going to school, or taking care of children or other responsibilities			[ ]	[ ]
c. You missed or were late for work, school, or other activities because you were drinking or hung over			[ ]	[ ]
d. You had a problem getting along with other people while you were drinking			[ ]	[ ]
e. You drove a car after having several drinks or after drinking too much			[ ]	[ ]

11. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?	Not difficult at all [ ]	Somewhat difficult [ ]	Very difficult [ ]	Extremely difficult [ ]

FOR OFFICE CODING: Bul Ner if #6a,b, and -c and #8 are all 'YES'; Bin Eat Dis the same but #8 either 'NO' or left blank. Alc Abu if any of #10a-e is 'YES'.

12. During the last 4 weeks, how much have you been bothered by any of the following problems?		Not bothered at all	Bothered a little	Bothered a lot
a. Worrying about your health		[ ]	[ ]	[ ]
b. Your weight or how you look		[ ]	[ ]	[ ]
c. Little or no sexual desire or pleasure during sex		[ ]	[ ]	[ ]
d. Difficulties with husband/wife, partner/lover, or boyfriend/girlfriend		[ ]	[ ]	[ ]
e. The stress of taking care of children, parents, or other family members		[ ]	[ ]	[ ]
f. Stress at work or outside of the home or at school		[ ]	[ ]	[ ]
g. Financial problems or worries		[ ]	[ ]	[ ]
h. Having no one to turn to when you have a problem		[ ]	[ ]	[ ]
i. Something bad that happened recently		[ ]	[ ]	[ ]
j. Thinking or dreaming about something terrible that happened to you in the past - like your house being destroyed, a severe accident, being hit or assaulted, or being forced to commit a sexual act		[ ]	[ ]	[ ]

13. In the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone, or has anyone forced you to have an unwanted sexual act?			No [ ]	Yes [ ]

14. What is the most stressful thing in your life right now? ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________

15. Are you taking any medicine for anxiety, depression, or stress?			No [ ]	Yes [ ]

16. FOR WOMEN ONLY: Questions about menstruation, pregnancy, and childbirth
a. Which best describes your menstrual periods?
___ Periods are unchanged
___ No periods because pregnant or recently gave birth
___ Periods have become irregular or changed in frequency, duration, or amount
___ No periods for at least a year
___ Having periods because taking hormone replacement (estrogen) therapy or oral contraceptive
b. During the week before your period starts, do you have a serious problem with your mood - like depression, anxiety, irritability, anger, or mood swings?			No	Yes
			[ ]	[ ]
- If Yes: Do these problems go away by the end of your period?			[ ]	[ ]
c. Have you given birth within the last 6 months?			[ ]	[ ]
d. Have you had a miscarriage within the last 6 months?			[ ]	[ ]
e. Are you having difficulty getting pregnant?			[ ]	[ ]

(DO NOT DISTRIBUTE THIS PAGE TO THE PATIENT)
Quick guide to the patient health questionnaire
Purpose. The Patient Health Questionnaire (PHQ) is designed to facilitate the recognition and diagnosis of the most common mental disorders in primary care patients. For patients with a depressive disorder, a PHQ Depression Severity Index score can be calculated and repeated over time to monitor change.
Who should take the PHQ. Ideally, the PHQ should be used with all new patients, all patients who have not completed the questionnaire in the last year, and all patients suspected of having a mental disorder.
Making a diagnosis. Since the questionnaire relies on patient self-report, definitive diagnoses must be verified by the clinician, taking into account how well the patient understood the questions in the questionnaire, as well as other relevant information from the patient, their family, or other sources.
Interpreting the PHQ. To facilitate interpretation of patient responses, all clinically significant responses are found in the column farthest to the right. (The only exception is for suicidal ideation when diagnosing a depressive syndrome.) In addition, the diagnoses of Major Depressive Disorder (rather than Syndrome) and Other Depressive Disorder requires ruling out normal bereavement (mild symptoms, duration less than 2 months), a history of a manic episode (Bipolar Disorder), and a physical disorder, medication, or other drug as the biological cause of the depressive symptoms. Similarly, the diagnoses of Panic Disorder and Other Anxiety Disorder require ruling out a physical disorder, medication, or other drug as the biological cause of the anxiety symptoms. Criteria for diagnostic judgments for summarizing responses are located at different points, beginning with "FOR OFFICE CODING", in small type. The names of the categories are abbreviated (eg, Major Depressive Syndrome is Maj Dep Syn).
Page 1
Somatoform Disorder if at least 3 of #1a-m bother the patient "a lot" and lack an adequate biological explanation.
Major Depressive Syndrome if #2a or b and 5 or more of #2a-i are at least "more than half the days" (count #2i if present at all).
Other Depressive Syndrome if #2a or b and 2, 3 or 4 of #2a-i are at least "more than half the days" (count #2i if present at all).
NOTE: The diagnoses of Major Depressive Disorder and Other Depressive Disorder requires ruling out normal bereavement (mild symptoms, duration less than 2 months), a history of a manic episode (Bipolar Disorder) and a physical disorder, medication, or other drug as the biological cause of the depressive symptoms.
Page 2
Panic Syndrome if #3a-d are all 'Yes' and 4 or more of #4a-k are 'Yes'.
Other Anxiety Syndrome if #5a and answers to 3 or more of #5b-g are "more than half the days."
NOTE: The diagnoses of Panic Disorder and Other Anxiety Disorder require ruling out a physical disorder, medication, or other drug as the biological cause of the anxiety symptoms.
Page 3
Bulimia Nervosa if #6a,b, and c and #8 are 'Yes'; Binge Eating Disorder the same but #8 is either 'No' or left blank.
Alcohol abuse if any of #10a-e are 'Yes'.
Additional clinical considerations. After making a provisional diagnosis with the PHQ, there are additional clinical considerations that may affect decisions about management and treatment:
Have current symptoms been triggered by psychosocial stressor(s)?
What is the duration* of the current disturbance and has the patient received any treatment for it?*
To what extent are the patient's symptoms impairing* their usual work and activities?*
Is there a history* of similar episodes, and were they treated?*
Is there a family history* of similar conditions?*

Graphic 82674 Version 5.0

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Patient health questionnaire (PHQ)