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Personal-Health-Questionnaire-PHQ-1597
During the
past 4 weeks
, how much have you been bothered by any of the following
problems?
(select
the best
response for each
question)
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Email
*
Your email
Your Full Name
*
Your answer
Please choose Time 1, 2, 3 or 4 from the drop-down menu below depending on whether you are completing this form for the first, second (3 months), third (6 months) or fourth (9 months) time
*
Choose
Time 1
Time 2
Time 3
Time 4
a. Stomach pain
*
(0) Not bothered at all
(1) Bothered a little
(2) Bothered a lot
b. Back pain
*
(0) Not bothered at all
(1) Bothered a little
(2) Bothered a lot
c. Pain in your arms, legs, or joints (knees, hips, etc.)
*
(0) Not bothered at all
(1) Bothered a little
(2) Bothered a lot
d. Menstrual cramps or other problems with your periods [
Women only
]
(0) Not bothered at all
(1) Bothered a little
(2) Bothered a lot
Clear selection
e. Headaches
*
(0) Not bothered at all
(1) Bothered a little
(2) Bothered a lot
f. Chest pain
*
(0) Not bothered at all
(1) Bothered a little
(2) Bothered a lot
g. Dizziness
*
(0) Not bothered at all
(1) Bothered a little
(2) Bothered a lot
h. Fainting spells
*
(0) Not bothered at all
(1) Bothered a little
(2) Bothered a lot
i. Feeling your heart pound or race
*
(0) Not bothered at all
(1) Bothered a little
(2) Bothered a lot
j. Feeling your heart pound or race
*
(0) Not bothered at all
(1) Bothered a little
(2) Bothered a lot
k. Pain or problems during sexual intercourse
*
(0) Not bothered at all
(1) Bothered a little
(2) Bothered a lot
l. Constipation, loose bowels, or diarrhea
*
(0) Not bothered at all
(1) Bothered a little
(2) Bothered a lot
m. Nausea, gas, or indigestion
*
(0) Not bothered at all
(1) Bothered a little
(2) Bothered a lot
n. Feeling tired or having low energy
*
(0) Not bothered at all
(1) Bothered a little
(2) Bothered a lot
o. Trouble sleeping
*
(0) Not bothered at all
(1) Bothered a little
(2) Bothered a lot
Please count all the numbers and put total score below:
Your answer
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