PHYSICAL SYMPTOMS

(PHQ-15)

During the past 4 weeks, how much have you been bothered by any of the following problems?

Not Bothered Bothered

bothered a a
at all little lot
(0) (1) (2)

a. Stomach pain F F F

b. Back pain F F F

c. Pain in your arms, legs, or joints (knees, hips, etc.) F F F

d. Menstrual cramps or other problems with your periods F F F

WOMEN ONLY

e. Headaches F F F

f. Chest pain F F F

g. Dizziness F F F

h. Fainting spells F F F

i. Feeling your heart pound or race F F F

j. Shortness of breath F F F

k. Pain or problems during sexual intercourse F F F

l. Constipation, loose bowels, or diarrhea F F F

m. Nausea, gas, or indigestion F F F

n. Feeling tired or having low energy F F F

o. Trouble sleeping F F F

(For office coding: Total Score T_____ = _____ + _____ )

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant
from Pfizer Inc. No permission required to reproduce, translate, display or distribute.