Sladich Counseling Patient Health Questionnaire
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.

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Client's Name *
Age *
How much have you been bothered by any of the following problems?   *
Not bothered
Bothered a little
Bothered a lot
Headaches
Pain in back, arms, legs, or joints (knees, hips, etc.)
Uncontrollable emotions
Avoidance of certain people
Avoidance of certain places
Avoidance of certain situations
Romantic / sex life satisfaction
Home / family life satisfaction
Work life satisfaction
Social life satisfaction
Lack of exercise
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
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself — or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
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
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