| RPT |
.| .| Patient Health Questionnaire 15-Item Somatic Symptom Severity Scale| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran:
<.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | PHQ-15 Score: <-PHQ-15 Score->| | Minimal 0-4| Low
5-9| Medium 10-14| High 15-30| | | Questions and Answers| | a. Stomach pain| <*Answer_5191*>| b. Back pain| <*Answer_5192*>| c. Pain in your arms, legs, or joints (knees, hips,
etc.)| <*Answer_5297*>| d. Menstrual cramps or other problems with your periods [Women only]| <*Answer_5298*>| e. Headaches| <*Answer_5299*>| f. Chest pain| <*Answer_5300*>| g.
Dizziness| <*Answer_5301*>| h. Fainting spells| <*Answer_5302*>| i. Feeling your heart pound or race| <*Answer_5303*>| j. Shortness of breath| <*Answer_5304*>| k. Pain or problems
during sexual intercourse| <*Answer_5305*>| l. Constipation, loose bowels, or diarrhea| <*Answer_5306*>| m. Nausea, gas, or indigestion| <*Answer_5307*>| n. Feeling tired or having low
energy| <*Answer_5308*>| o. Trouble sleeping| <*Answer_5400*>| | Copyright (c) 1999 Pfizer Inc. All rights reserved. Reproduced with permission.| | Information contained in this note is
based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment results should be verified for accuracy and used in conjunction with other diagnostic
activities and procedures.| $~
|
