Patient Health Questionnaire – PHQ - Arch Health Partners

Thomas R. Knutson, M.D.Patient Health Questionnaire – PHQPatient Name: _______________________________DOB: _______________________________MRN: _______________________________15. What is your occupation?HomemakerLaborerProfessional/Executivea. What is your current work status?Full-timePart-timeWhite Collar/SecretarialStudentTradespersonRetiredSelf-employedOther: ____________UnemployedOther: __________16. Do you smoke? Yes No If yes, number of packs per day: ____________17. List any prior surgeries or hospitalizations:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________18. List any allergies and reactions to medication:_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________19. List all prescriptions or over the counter medications you are currently taking:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Form # 14000Page 3 of 4Scan into NextGen

Thomas R. Knutson, M.D.Patient Name: _______________________________DOB: _______________________________MRN: _______________________________Patient Health Questionnaire – PHQIf you are being seen for your HIP or KNEE, please complete this section.1. Functiona. LimpNoneSlightModerateSevereUnable to Walkb. Distance WalkedUnlimited6 Blocks2-3 BlocksIndoors OnlyBed to Chairc. StairsNormalHandrail NeededNo Stairsd. SittingAs long as neededLimitedUncomfortablee. Socks/ShoesLeftWith EaseWith DifficultyUnableRightWith EaseWith DifficultyUnablef. Cut ToenailsLeftWith EaseWith DifficultyUnableRightWith EaseWith DifficultyUnable2. Do you have night pain? Yes No3. Do you have pain while resting? Yes No4. Do you have pain on arising from sitting? Yes No5. Is your pain worsened by:a. Going upstairs? Yes Nob. Going downstairs? Yes NoKNEE ONLY6. Does your knee give out or buckle? Yes No7. Does your knee “catch” or “lock up”? Yes No8. Can you squat? Yes NoForm # 14000Page 4 of 4Scan into NextGen