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