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 Full Name *
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 *
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 [Women only]
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e.  Headaches *
f. Chest pain *
g. Dizziness  *
h. Fainting spells  *
i. Feeling your heart pound or race  *
j. Feeling your heart pound or race  *
k. Pain or problems during sexual intercourse *
l.  Constipation, loose bowels, or diarrhea  *
m.  Nausea, gas, or indigestion  *
n. Feeling tired or having low energy  *
o. Trouble sleeping *
Please count all the numbers and put total score below:
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