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Sample پرسشنامه علائم جسمانی PHQ-15

پرسشنامه سلامت بیمار PHQ-15 برای سنجش شدت علائم جسمانی در چهار هفته‌ی گذشته با ۱۵ سؤال؛ نمره‌ی ۰ تا ۳۰ و سطح شدت (حداقل، کم، متوسط، زیاد) خودکار حساب و برای پاسخ‌دهنده تفسیر می‌شود.

15 questions · Free up to 50 responses a month

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About this template

“پرسشنامه علائم جسمانی PHQ-15” has 15 questions; 14 are required and 1 optional. Question types: Single choice (15). 45 ready-made options across 15 choice questions, all editable in the online version.

Related:Standard questionnairesBuild an online questionnaireCronbach's alpha calculatorSample size calculation

Questions in this template

  1. 1.

    معده‌درد یا دل‌درد *

    (Single choice)
    • اصلاً آزارم نداده
    • کمی آزارم داده
    • خیلی آزارم داده
  2. 2.

    کمردرد *

    (Single choice)
    • اصلاً آزارم نداده
    • کمی آزارم داده
    • خیلی آزارم داده
  3. 3.

    درد در دست‌ها، پاها یا مفصل‌ها (زانو، لگن و …) *

    (Single choice)
    • اصلاً آزارم نداده
    • کمی آزارم داده
    • خیلی آزارم داده
  4. 4.

    دردِ قاعدگی یا مشکل‌های دیگرِ دوره‌ی ماهانه (فقط بانوان پاسخ دهند)

    (Single choice)

    آقایان این پرسش را بی‌پاسخ بگذارند.

    • اصلاً آزارم نداده
    • کمی آزارم داده
    • خیلی آزارم داده
  5. 5.

    سردرد *

    (Single choice)
    • اصلاً آزارم نداده
    • کمی آزارم داده
    • خیلی آزارم داده
  6. 6.

    دردِ قفسه‌ی سینه *

    (Single choice)
    • اصلاً آزارم نداده
    • کمی آزارم داده
    • خیلی آزارم داده
  7. 7.

    سرگیجه *

    (Single choice)
    • اصلاً آزارم نداده
    • کمی آزارم داده
    • خیلی آزارم داده
  8. 8.

    حمله‌های غش و از حال رفتن *

    (Single choice)
    • اصلاً آزارم نداده
    • کمی آزارم داده
    • خیلی آزارم داده
  9. 9.

    احساسِ کوبیدن یا تند زدنِ قلب *

    (Single choice)
    • اصلاً آزارم نداده
    • کمی آزارم داده
    • خیلی آزارم داده
  10. 10.

    تنگیِ نفس *

    (Single choice)
    • اصلاً آزارم نداده
    • کمی آزارم داده
    • خیلی آزارم داده
  11. 11.

    درد یا مشکل هنگامِ رابطه‌ی جنسی *

    (Single choice)
    • اصلاً آزارم نداده
    • کمی آزارم داده
    • خیلی آزارم داده
  12. 12.

    یبوست، شلیِ مدفوع یا اسهال *

    (Single choice)
    • اصلاً آزارم نداده
    • کمی آزارم داده
    • خیلی آزارم داده
  13. 13.

    حالتِ تهوع، نفخ یا سوءهاضمه *

    (Single choice)
    • اصلاً آزارم نداده
    • کمی آزارم داده
    • خیلی آزارم داده
  14. 14.

    احساسِ خستگی یا کم‌انرژی بودن *

    (Single choice)
    • اصلاً آزارم نداده
    • کمی آزارم داده
    • خیلی آزارم داده
  15. 15.

    مشکلِ خواب *

    (Single choice)
    • اصلاً آزارم نداده
    • کمی آزارم داده
    • خیلی آزارم داده

What does the PHQ-15 measure?

The severity of somatic (physical) symptoms over the last four weeks: pain in different parts of the body, gastrointestinal and cardiopulmonary symptoms, fatigue and sleep problems. It is the somatic-symptom module of the Patient Health Questionnaire (PHQ) and is used in primary care and research to measure and follow somatic symptom burden.

Number of items
15
Time to complete
About 3 minutes
Score range
0 to 30
Reversed items
None
Response scale
Three options: not bothered at all (0), bothered a little (1), bothered a lot (2)
Authors
Kurt Kroenke, Robert Spitzer and Janet Williams, 2002

This questionnaire is a screening tool, not a diagnosis; physical symptoms can have medical causes that only a doctor can assess. If you feel severe distress or have thoughts of harming yourself, call Iran's social emergency line 123 or the counselling line 1480 now.

Scoring the PHQ-15

  1. Not bothered at all = 0, bothered a little = 1, bothered a lot = 2.
  2. The total is the sum of the fifteen items, from 0 to 30; there are no reversed items.
  3. Item 4 (menstrual cramps) is for women only and men leave it blank; the total is the sum of the answered items (a maximum of 28 for men).
  4. In this template every option already carries its score and a calculated field adds them up with SCORE() and assigns the severity level.

Interpreting PHQ-15 scores

ScoreLevelSuggested action
0–4Minimal—
5–9Low—
10–14Medium—
15–30High—

Kroenke et al. (2002) proposed scores of 5, 10 and 15 as the thresholds for low, medium and high somatic symptom severity. The official PHQ manual calls a score of 10 or more a "yellow flag" and 15 or more a "red flag".

PHQ-15 validity and reliability

  • Kroenke et al. (2002) administered the PHQ-15 to 6,000 patients in eight general internal medicine and family practice clinics and seven obstetrics–gynaecology clinics.
  • As PHQ-15 scores rose, functional status worsened step by step on all six SF-20 subscales, and symptom-related difficulty, sick days and clinic visits increased; results were similar in both clinic samples.

Using the PHQ-15 in your thesis with Porsino

  1. Sign up for free and click "Build a form from this template"; the items, options and every option's score (reversed items included) are ready.
  2. If you need demographic questions (age, gender, education), add them on a separate page; keep the item wording and order unchanged so the scoring stays valid.
  3. Publish the form and send its short link or QR code to your research sample; respondents fill it in without signing up and see their score and its interpretation at the end.
  4. Each respondent's total score and level are saved automatically in separate columns; export to Excel or SPSS from the responses page and go straight to analysis.
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Source and translation

Original instrument: Kurt Kroenke, Robert Spitzer and Janet Williams, 2002

  • Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2002). The PHQ-15: Validity of a new measure for evaluating the severity of somatic symptoms. Psychosomatic Medicine, 64(2), 258–266.

According to the official PHQ manual, all instruments in the family, including the PHQ-15, are in the public domain, and no permission is required to reproduce, translate, display or distribute them.

Translated by Porsino; for formal research, cite a validated (normed) Persian version.

Frequently asked questions about the PHQ-15

How many items does the PHQ-15 have?

Fifteen physical symptoms with three options (0–2); the total runs from 0 to 30 and the menstrual-cramps item is for women only.

How is the PHQ-15 score interpreted?

0–4 minimal, 5–9 low, 10–14 medium and 15–30 high; these thresholds come from the developers' article (Kroenke et al., 2002).

How is the PHQ-15 different from the PHQ-9?

Both belong to the Patient Health Questionnaire family; the PHQ-9 measures depressive symptom severity over two weeks and the PHQ-15 somatic symptom severity over four weeks.

Printable or online?

Printable version (Word & PDF)

  • For filling in on paper, signing and filing by hand
  • Edit the Word file any way you like
  • Collecting and typing up the answers is up to you
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Online version on Porsino

  • Answers are collected and organised automatically — no retyping
  • National ID, mobile number and dates are validated instantly
  • Ready-made reports and charts, plus Excel export in one click
  • Share a link or QR code — it works on mobile too
Build the online version for free

How do I use this template?

  1. Sign up for Porsino for free; no bank card needed.
  2. In the panel, open “Templates” and choose “پرسشنامه علائم جسمانی PHQ-15”.
  3. Change the questions as you like, publish the form and send the link.

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