NOTE: The form for the questionnaire is on page 1750, Spitzer et al (1994). The copyright is held by Pfizer Inc, but can be photocopied as needed.
Instructions:
The questionnaire will help your doctor better understand problems that you may have. Your doctor may ask you more questions about some of these items. Please make sure to check a box for every item.
Items:
(1) things bothering during the month: 21 items
(2) events during the past month: 5 items
(3) 5 point Likert scale on health (from excellent to poor)
Responses:
(1) 26 questions: yes or no
(2) overall health: one of the 5 options
Conditions screened for:
(1) somatoform disorders: 16 (questions 1-16)
(2) eating disorder: 1 (question 17)
(3) depression: 2 (questions 18-19)
(4) anxiety: 3 (questions 20-22)
(5) alcohol usage: 4 (questions 23-26)
