Welcome to your Illness Questionnaire

This DSM-5 Level 2—Somatic Symptom—Adult measure is an adaptation of the 15-item Patient Health Questionnaire Physical Symptoms (PHQ-15) that assesses the domain of somatic symptoms.

This measure was adapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15]), which is in the public domain (http://www.phqscreeners.com/instructions/instructions.pdf). The original measure was developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc.
To request permission for any other use beyond what is stipulated above, contact: The measure is in the public domain and can be used without permission.

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 selecting one answer per question.
1. 
Stomach pain
2. 
Back pain
3. 
Pain in your arms, legs, or joints (knees, hips, etc.)
4. 
Menstrual cramps or other problems with your periods WOMEN ONLY
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 diarrhea
13. 
Nausea, gas, or indigestion
14. 
Feeling tired or having low energy
15. 
Trouble sleeping

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