Physical Health Questionnaires

If you would prefer to fill in any of these questionnaires offline you can download a pdf by clicking on the link.

Patient Health Questionnaire - Physical symptoms (PHQ-15)

During the past 4 weeks, how much have you been bothered by any of the following problems?	Not bothered at all (or not applicable)	Bothered a little	Bothered a lot
1. Stomach pain
2. Back pain
3. Pain in your arms, legs, or joints (knees, hips etc.)
4. (Women only) Menstrual cramps or other problems with your periods
5. Headaches
6. Chest pain
7. Dizziness
8. Fainting spells
9. Feeling your heart pound or race
10. Shortness of breath
11. Pain or problems during sexual intercourse
12. Constipation, loose bowels or diarrhoea
13. Nausea, gas, or indigestion
14. Feeling tired or having low energy
15. Trouble sleeping

The range of scores on the PHQ-15 is 0-30.

Kocalevent et al. (2013) state that evidence supports the PHQ-15 as a valid and reliable measure of somatisation symptoms. The American Psychiatric Association states the following levels of somatic symptom severity: 0-4 "minimal; 5-9 "low"; 10-14 "medium"; and 15-30 "high".

References

American Psychiatric Association (n.d.). LEVEL 2 - Somatic symptom - Adult patient. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_Level-2-Somatic-Symptom-Adult.pdf
Kocalevent, RD., Hinz, A. & Brähler, E. (2013). Standardization of a screening instrument (PHQ-15) for somatization syndromes in the general population. BMC Psychiatry 13, 91. https://doi.org/10.1186/1471-244X-13-91
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2002). The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosomatic Medicine, 64(2), 258-266.

Francis Irritable Bowel Scale (IBS-SSS)

Question 1: How severe has your abdominal (tummy) pain been in the past 10 days? (Please select a number from 0 to 10 with 0 meaning "no pain" and 10 meaning "very severe pain")
Question 2: On how many of the last ten days did you get pain. (For example, if you select 4 it means you had pain on 4 out of 10 days. If you have pain every day, select 10)
Question 3: How severe has your abdominal distension (bloating, swollen, or tight tummy) been over the last ten days? (Please select a number from 0 to 10 with 0 meaning "no distension or bloating" and 10 meaning "very severe distension or bloating")
Question 4: How satisfied have you been with your bowel habit (frequency, ease etc.) over the past ten days? (Please select a number from 0 to 10 with 0 meaning "very happy" and 10 meaning "very unhappy")
Question 5: how much has your IBS been affecting/interfering with your life in general over the last ten days? (Please select a number from 0 to 10 with 0 meaning "not at all" and 10 meaning "completely")

The range of scores for the IBS-SSS is 0-500. Francis et al. (1997) report that a score of 75-175 indicates "mild" severity, 175-300 "moderate" severity, and 300 plus "severe" severity.

Reference

Francis, C. Y., Morris, J., & Whorwell, P. J. (1997). The irritable bowel severity scoring system: A simple method of monitoring irritable bowel syndrome and its progress. Alimentary Pharmacology & Therapeutics, 11(2), 395-402.

Chalder Fatigue Questionnaire (CFQ)

We would like to know more about any problems you have had with feeling tired, weak or lacking in energy in the last month. Please answer ALL the questions by ticking the answer which applies to you most closely. If you have been feeling tired for a long while, then compare yourself to how you felt when you were last well. Please select only one button per line.

	Less than usual	No more than usual	More than usual	Much more than usual
1. Do you have problems with tiredness?
2. Do you need rest more?
3. Do you feel sleepy or drowsy?
4. Do you have problems starting things?
5. Do you lack energy?
6. Do you have less strength in your muscles?
7. Do you feel weak?
8. Do you have difficulties concentrating?
9. Do you make slips of the tongue when speaking?
10. Do you find it more difficult to find the right word?
	Better than usual	No worse than usual	Worse than usual	Much worse than usual
11. How is your memory?

The range of scores for the CFQ is 0-33.

Cella and Chalder (2010) report that the mean (average) score for people with chronic fatigue syndrome was 24.4 compared to a community sample average score of 14.2. They also state that a score of 29 discriminated between CFS sufferers and the community sample in 96% of cases and a score in the 30s discriminated in 100% of cases. The CFS sufferers also scored a mean of 26.99 on the Work & Social Adjustment Scale

Reference

Cella, M., & Chalder, T. (2010). Measuring fatigue in clinical and community settings. Journal of Psychosomatic Research, 69(1), 17-22.

Which questionnaires do you wish to export? PHQ-15 FIB-SSS CFQ

Important

Please treat your scores on these or any other online questionnaires with caution. Questionnaires cannot be used to make a diagnosis of a mental health condition. Where a mental health condition has been diagnosed by a suitably qualified and experienced health professional these questionnaires may be used as a guide to the current severity of your condition. Always consult with a qualified health professional if you are concerned in any way about your mental health.

If you are worried about your safety, you should immediately consult with your GP or another suitably qualified health professional. If you are in the UK the following numbers might be of help to you:

NHS Emergencies: call 999.
NHS Non-emergency number: call 111.
Samaritans: call 116 123 or email jo@samaritans.org

You can find more guidance and additional helpline numbers on this NHS page: Help for suicidal thoughts

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