Patient Health Questionnaire

Email *

Phone *

Address *

ZIP / Postal Code *

Occupation *

Job Description

Name of your Medical Doctor *

Specialty—Please choose an option—Medical DoctorGeneral PractitionerOsteopathChiropractorPhysiotherapistHospitalistSurgeonCardiologistDermatologistEndocrinologistGastroenterologistObstetricianOtolaryngologistMassage TherapistCertified TrainerOther

Contact Phone

Contact Email

Doctor / Therapist Name

Specialty—Please choose an option—Medical DoctorGeneral PractitionerOsteopathChiropractorPhysiotherapistHospitalistSurgeonCardiologistDermatologistEndocrinologistGastroenterologistObstetricianOtolaryngologistMassage TherapistCertified TrainerOther

Phone

Email

Doctor / Therapist Name

Specialty—Please choose an option—Medical DoctorGeneral PractitionerOsteopathChiropractorPhysiotherapistHospitalistSurgeonCardiologistDermatologistEndocrinologistGastroenterologistObstetricianOtolaryngologistMassage TherapistCertified TrainerOther

Phone

Email

Is it getting worse? *—Please choose an option—YesNo

Have you lost work time? *—Please choose an option—YesNo

Does it interfere with sleep? *—Please choose an option—YesNo

Does it interfere with work? *—Please choose an option—YesNo

Does it interfere with daily routine? *—Please choose an option—YesNo

Was it result of an accident? *—Please choose an option—Yes, car accidentYes, on the jobYesNo

Forwards *

Backwards *

Sideways *

Forwards *

Backwards *

Sideways *

High Blood Pressure / Hypertension *—Please choose an option—YesNo

Comment

Neck pain — where? *—Please choose an option—YesNo

Comment

Joint degeneration and/or Arthritis *—Please choose an option—YesNo

Comment

Haemophilia or other blood disease *—Please choose an option—YesNo

Comment

Diabetes *—Please choose an option—YesNo

Comment

Osteoporosis or Osteopenia *—Please choose an option—YesNo

Comment

Whiplash injury / cervical sprain *—Please choose an option—YesNo

Comment

Numbness in the hands or fingers *—Please choose an option—YesNo

Comment

Have any relatives ever suffered a stroke? *—Please choose an option—YesNo

Comment

Have you had cortisone shots? *—Please choose an option—YesNo

Comment

How is pain at its worst? *0 – No Pain1 – Very Mild2 – Discomforting3 – Tolerable4 – Distressing5 – Very Distressing6 – Intense7 – Very Intense8 – Utterly Horrible9 – Excruciating Unbearable10 – Worst pain Imaginable

When lying on involved side? *0 – No Pain1 – Very Mild2 – Discomforting3 – Tolerable4 – Distressing5 – Very Distressing6 – Intense7 – Very Intense8 – Utterly Horrible9 – Excruciating Unbearable10 – Worst pain Imaginable

Reaching for something on a high shelf *0 – No Pain1 – Very Mild2 – Discomforting3 – Tolerable4 – Distressing5 – Very Distressing6 – Intense7 – Very Intense8 – Utterly Horrible9 – Excruciating Unbearable10 – Worst pain Imaginable

Touching the back of your neck? *0 – No Pain1 – Very Mild2 – Discomforting3 – Tolerable4 – Distressing5 – Very Distressing6 – Intense7 – Very Intense8 – Utterly Horrible9 – Excruciating Unbearable10 – Worst pain Imaginable

Pushing with the involved arm? *0 – No Pain1 – Very Mild2 – Discomforting3 – Tolerable4 – Distressing5 – Very Distressing6 – Intense7 – Very Intense8 – Utterly Horrible9 – Excruciating Unbearable10 – Worst pain Imaginable

Washing your hair? *0 – No Pain1 – Very Mild2 – Discomforting3 – Tolerable4 – Distressing5 – Very Distressing6 – Intense7 – Very Intense8 – Utterly Horrible9 – Excruciating Unbearable10 – Worst pain Imaginable

Washing your back? *0 – No Pain1 – Very Mild2 – Discomforting3 – Tolerable4 – Distressing5 – Very Distressing6 – Intense7 – Very Intense8 – Utterly Horrible9 – Excruciating Unbearable10 – Worst pain Imaginable

Putting on an undershirt or jumper? *0 – No Pain1 – Very Mild2 – Discomforting3 – Tolerable4 – Distressing5 – Very Distressing6 – Intense7 – Very Intense8 – Utterly Horrible9 – Excruciating Unbearable10 – Worst pain Imaginable

Putting on a shirt that buttons down the front? *0 – No Pain1 – Very Mild2 – Discomforting3 – Tolerable4 – Distressing5 – Very Distressing6 – Intense7 – Very Intense8 – Utterly Horrible9 – Excruciating Unbearable10 – Worst pain Imaginable

Putting on your pants? *0 – No Pain1 – Very Mild2 – Discomforting3 – Tolerable4 – Distressing5 – Very Distressing6 – Intense7 – Very Intense8 – Utterly Horrible9 – Excruciating Unbearable10 – Worst pain Imaginable

Placing an object on a high shelf? *0 – No Pain1 – Very Mild2 – Discomforting3 – Tolerable4 – Distressing5 – Very Distressing6 – Intense7 – Very Intense8 – Utterly Horrible9 – Excruciating Unbearable10 – Worst pain Imaginable

Carrying a heavy object of 10 pounds / 4.5kg? *0 – No Pain1 – Very Mild2 – Discomforting3 – Tolerable4 – Distressing5 – Very Distressing6 – Intense7 – Very Intense8 – Utterly Horrible9 – Excruciating Unbearable10 – Worst pain Imaginable

Removing something from your back pocket? *0 – No Pain1 – Very Mild2 – Discomforting3 – Tolerable4 – Distressing5 – Very Distressing6 – Intense7 – Very Intense8 – Utterly Horrible9 – Excruciating Unbearable10 – Worst pain Imaginable

Right Shoulder — File 1

Right Shoulder — File 2

Left Shoulder — File 1

Left Shoulder — File 2

Neck — File 1

Neck — File 2

Medical Report — File 1

Medical Report — File 2

MRI