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Patient Health Questionnaire (PHQ-15) PDF Free Download
PHQ-15 – Patient Health Questionnaire 15 PDF
Name: ________________ Age: _………. Sex: ……. Male …… Female……………. Date:______
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? __hours/week
Instructions: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by “unexplained aches and pains”, and/or “feeling that your illnesses are not being taken seriously enough” at a mild or greater level of severity.
The questions below ask about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days. Please respond to each item by marking ( or x) one box per row.
Clinician Use
During the past 7 days, how much have you been bothered by any of the following problems? Item Score
Not bothered at all (0)
Bothered a little (1)
Bothered a lot (2)
- Stomach pain
- Back pain
- Pain in your arms, legs, or joints (knees, hips, etc.)
- Menstrual cramps or other problems with your periods WOMEN ONLY
- Headaches
- Chest pain
- Dizziness
- Fainting spells
- Feeling your heart pound or race
- Shortness of breath
- Pain or problems during sexual intercourse
- Constipation, loose bowels, or diarrhea
- Nausea, gas, or indigestion
- Feeling tired or having low energy
- Trouble sleeping
Total/Partial Raw Score: Prorated Total Raw Score: (if 1-3 items left unanswered)
Instructions to Clinicians
DSM-5 Level 2 – Somatic Symptoms – Adult Scale is an adaptation of the 15-item Patient Health Questionnaire Physical Symptoms (PHQ-15) which assesses the domain of somatic symptoms. The measure is completed by the individual (or his informant) prior to meeting with the therapist. If the person is of impaired capacity and is unable to complete the form (for example, a person with dementia), a knowledgeable informant may complete the measure. Each item asks the individual (or the informant) to rate the severity of the individual’s somatic symptom during the past 7 days.
Scoring and Interpretation
Each item on the PHQ-15 is rated on a 3-point scale (0=not bothered at all; 1=bothered a little; 2= bothered a lot). The total score can range from 0 to 30, with higher scores indicating greater severity of somatic symptoms.
During the clinical interview, the clinician is asked to review the score for each item on the measure and to indicate the raw score for each item in a section provided for “clinician use”. The raw scores on the 15 items are to be summed up and interpreted using interpretation to obtain a total raw score. Table for the PHQ-15 Somatic Symptom Severity scale below:
Interpretation Table for the PHQ-15 Somatic Symptom Severity scale Levels of Somatic Symptom Severity PHQ-15 Score
Minimal 0-4
Low 5-9
Medium 10-14
High 15-30
| Language | English |
| No. of Pages | 3 |
| PDF Size | 0.3 MB |
| Category | Health |
| Source/Credits | psychiatry.org |
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