GRACE COTTAGE: Patient Health Questionnaire Physical Symptoms (PHQ-15)
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Email *
Last Name
First Name
Phone Number *
Date of Birth *
MM
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DD
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YYYY
Sex
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If the measure is being completed by an informant, what is your relationship with the individual receiving care?
In a typical week, approximately how much time do you spend with the individual receiving care?
During the past 7 days, how much have you been bothered by any of the following problems?
Stomach pain
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Back pain
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Pain in your arms, legs, or joints (knees, hips, etc.)
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Menstrual cramps or other problems with your periods WOMEN ONLY
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Headaches
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Chest pain
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Dizziness
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Fainting spells
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Feeling your heart pound or race
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Shortness of breath
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Pain or problems during sexual intercourse
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Constipation, loose bowels, or diarrhea
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Nausea, gas, or indigestion
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Feeling tired or having low energy
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Trouble sleeping
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