You can always press Enter⏎ to continue
Buffington Family Medicine
Current Symptom Questionnaire - Please complete the following questionnaire as soon as possible!
START
1
Date
Date
Month
Day
Year
Previous
Next
Submit
Press
Enter
2
Email
example@example.com
Previous
Next
Submit
Press
Enter
3
Please enter your name below:
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
4
General
*
This field is required.
Select any/all that you have experienced in the past 2 days:
NONE
Feeling Tired
Feeling Weak
Fever or Chills
Body aches
Recent weight gain or loss
Previous
Next
Submit
Press
Enter
5
1
2
3
4
5
Previous
Next
Submit
Press
Enter
6
Ear, Nose, and Throat
*
This field is required.
Select any/all that you have experienced in the past 2 days:
NONE
Nasal congestion
Difficulty swallowing
Nasal Drainage
Sore throat
Earache
Previous
Next
Submit
Press
Enter
7
1
2
3
4
5
Previous
Next
Submit
Press
Enter
8
Urinary
*
This field is required.
Select any/all that you have experienced in the past 2 days:
NONE
Pain during urination
Urinating more than 1 time at night
Increased/decreased urination
Blood in urine
Previous
Next
Submit
Press
Enter
9
1
2
3
4
Previous
Next
Submit
Press
Enter
10
Gastrointestinal
*
This field is required.
Select any/all that you have experienced in the past 2 days:
NONE
Decreased appetite
Abdominal pain
Nausea or vomiting
Diarrhea
Constipation
Heartburn
Blood in stool
Previous
Next
Submit
Press
Enter
11
1
2
3
4
5
6
7
Previous
Next
Submit
Press
Enter
12
Skin and Musculoskeletal
*
This field is required.
Select any/all that you have experienced in the past 2 days:
NONE
New or changing moles
Neck pain
Joint Pain
Back Pain
Previous
Next
Submit
Press
Enter
13
1
2
3
4
Previous
Next
Submit
Press
Enter
14
Chest
*
This field is required.
Select any/all that you have experienced in the past 2 days:
NONE
Cough
Excessively loud snoring
Shortness of breath
Heart racing
Heart skipping beats
Chest pain or discomfort
Chest tightness
Previous
Next
Submit
Press
Enter
15
1
2
3
4
5
6
7
Previous
Next
Submit
Press
Enter
16
Endocrinology
*
This field is required.
Select any/all that you have experienced in the past 2 days:
NONE
Easy bruising
Excessive thirst
Excessive sweating
Temperature intolerance
Sweating heavily at night
Previous
Next
Submit
Press
Enter
17
1
2
3
4
5
Previous
Next
Submit
Press
Enter
18
Neurologic and Eyes
*
This field is required.
Select any/all that you have experienced in the past 2 days:
NONE
Headache
Ringing in the ears
Dizziness
Numbness or tingling
Decrease in strength
Red eyes
Sleep disturbances
Depression and/or anxiety
Previous
Next
Submit
Press
Enter
19
1
2
3
4
5
6
7
8
Previous
Next
Submit
Press
Enter
20
Women Only
Select any/all that you have experienced in the past 2 days:
NONE
Unexplained vaginal bleeding
Vaginal pain, itching, or burning
Vaginal Discharge
Previous
Next
Submit
Press
Enter
21
1
2
3
Previous
Next
Submit
Press
Enter
22
Over the past
2 weeks
, how often have you experienced
little interest or pleasure in doing things?
*
This field is required.
Not at all
More than half the days
Several days
Nearly every day
Previous
Next
Submit
Press
Enter
23
Over the past
2 weeks
, how often have you
felt down, depressed, or hopeless?
*
This field is required.
Not at all
More than half the days
Several days
Nearly every day
Previous
Next
Submit
Press
Enter
24
PHQ 2 Calculation
Previous
Next
Submit
Press
Enter
25
Over the last
2 weeks
, how often have you experienced
trouble falling or staying asleep, or sleeping too much
?
Not at all
More than half the days
Several days
Nearly every day
Previous
Next
Submit
Press
Enter
26
Over the last
2 weeks
, how often have you
felt tired or had little energy?
Not at all
More than half the days
Several days
Nearly every day
Previous
Next
Submit
Press
Enter
27
Over the last
2 weeks
, how often have you experienced a
poor appetite or overeating?
Not at all
More than half the days
Several days
Nearly every day
Previous
Next
Submit
Press
Enter
28
Over the last
2 weeks
, how often have you
felt bad about yourself - or that you are a failure or have let yourself or your family down?
Not at all
More than half the days
Several days
Nearly every day
Previous
Next
Submit
Press
Enter
29
Over the last
2 weeks
, how often have you experienced
trouble concentrating on things, such as reading the newspaper or watching television?
Not at all
More than half the days
Several days
Nearly every day
Previous
Next
Submit
Press
Enter
30
Over the last
2 weeks
, how often have you felt that you are
moving or speaking so slowly that others may notice. Or being more fidgety or restless than usual?
Not at all
More than half the days
Several days
Nearly every day
Previous
Next
Submit
Press
Enter
31
Over the last
2 weeks
, how often have you had
thoughts that you would be better off dead or hurting yourself in some way?
Not at all
More than half the days
Several days
Nearly every day
Previous
Next
Submit
Press
Enter
32
PHQ-9 Score:
Previous
Next
Submit
Press
Enter
33
Nurse Email:
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
33
See All
Go Back
Submit