PATIENT HEALTH QUESTIONNAIRE

Surname: / First name (s):
Ethnic Origin: / Date of Birth:
White or White British / Asian or Asian British
British / Indian
Irish / Pakistani
Any other White Background / Bangladeshi
Mixed / Any other Asian background
White and Black Caribbean / Black or Black British
White and Black African / Caribbean
White and Asian / African
Any other Mixed / Any other Black background
Other Ethnic Groups
Chinese
Other
Is English your first language? YES/NO / If No, please state your first language:
Current Symptom(s) Please provide a succinct summary of your current symptoms:
Allergies Do you have any allergies? If yes please give details:
Medical HistoryDo you suffer or have suffered from any of the following conditions, if yes since when?
Heart Disease / YES/NO / Since:
Stroke / YES/NO / Since:
Cancer / YES/NO / Since:
Diabetes Type I / YES/NO / Since:
Diabetes Type II / YES/NO / Since:
Asthma / YES/NO / Since:
High Blood Pressure / YES/NO / Since:
Epilepsy / YES/NO / Since:
High Cholesterol / YES/NO / Since:
Do you have any other existing medical conditions? If so what are they, since when?
Surgical History (any surgical procedures/operations you may have including when)
Family medical and surgical history(Do you have any medical problems in your family, which we should know about?
Relationship
Heart Disease / YES/NO
Stroke / YES/NO
Cancer / YES/NO
Diabetes Type I / YES/NO
Diabetes Type II / YES/NO
Asthma / YES/NO
High Blood Pressure / YES/NO
Epilepsy / YES/NO
High Cholesterol / YES/NO
Other (Please state)
FOR OPHTHALMOLOGY PATIENTS ONLY
Allergies: Do you have allergies to preservative in eye drops? / YES/NO
Medical History: Do you suffer or have suffered from any of the following conditions? Please tick all that apply
Eyelid, orbital or eye surgery Family glaucoma history
Past/current contact lens wear Amblyopia (‘lazy’eye)
Glaucoma Congenital eye/lid disease
Thyroid dysfunction Known thyroid eye disease
Hay fever/allergic disease Facial/lid aesthetic surgery
Stroke or facial palsy Eczema/other skin condition
Diabetes Raised blood pressure
Cardiac history or angina Breathlessness /respiratory
Nasal/sinus (ENT) history Tumor/cancer history
Anxiety/depression Other psychiatric history
LIFESTYLE

Do you drink alcohol?YES/NOIf YES, check the following

How often do you drink? / Never / Monthly or less / 2-4 times per month / 2-3 times per week / 4+ times per week
How many units do you drink per day? / 1-2 / 3-4 / 5-6 / 7-8 / 10+
How often you have 6 or more units on one occasion? / Never / Less than monthly / Monthly / Weekly / Daily or almost daily
How many units on average do you drink a week?

(Wine: 125ml glass = 1.5 units, 175ml glass = 2.0 units; 250ml glass = 3units, pint of lower strength lager/beer/cider = 2 units; pint of higher strength lager/beer/cider = 3 units; single small shot of spirit = 1 1unit)

Do you smoke? YES/NO / If YES – how many cigarettes on average per day?
How many cigarettes on average per week? / Age when you started:
Are you an Ex-Smoker? YES/NO / If YES, When did you quit?
Do you now use, or have you ever used drugs for recreational purposes? YES/NO
If YES, please tick all that apply: / Cocaine / Amphetamines / Marijuana
Heroin / Inhalant / Other
Have you quit? YES/NO / If YES, When did you quit?
Do you have a special diet? (Please state)

Do you exercise regularly? YES/ NO

If YES, what and how often?

Work and Social Adjustment Scale (WSAS)

People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your problems look at each section and determine on the scale provided how much your problem impairs your ability to carry out the activity. This assessment is not intended to be a diagnosis. If you are concerned about your results in any way, please speak with a qualified health professional.

If you’re retired or choose not to have a job for reasons unrelated to your problem, tick here

0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8
Not at all / Slightly / Definitely / Markedly / Very Severely
1 / Because of my [problem] myability to work is impaired. ‘0’ means ‘not at all impaired’ and ‘8’ means very severely impaired to the point I can't work. / 012345678
2 / Because of my [problem] myhome management (cleaning, tidying, shopping, cooking, looking after home or children, paying bills) is impaired. / 012345678
3 / Because of my [problem] mysocial leisure activities (with other people e.g. parties, bars, clubs, outings, visits, dating, home entertaining) are impaired. / 012345678
4 / Because of my [problem], my private leisure activities (done alone, such as reading, gardening, collecting, sewing, walking alone) are impaired. / 012345678
5 / Because of my [problem], my ability to form and maintain close relationships with others, including those I live with, is impaired. / 012345678
Total WSAS score =

The maximum score of the WSAS is 40, lower scores are better. Privacy - please note - this form does not transmit any information about you or your assessment scores. If you wish to keep your results, either print this document or save this file locally to your computer. If you click ‘save’ before closing, your results will be saved in this document. These results are intended as a guide to your health and are presented for educational purposes only. They are not intended to be a clinical diagnosis. If you are concerned in any way about your health, please consult with a qualified health professional.

“A WSAS score above 20 appears to suggest moderately severe or worse psychopathology. Scores between 10 and 20 are associated with significant functional impairment but less severe clinical symptomatology. Scores below 10 appear to be associated with subclinical populations. Whether such a pattern will generalise to other disorders (apart from OCD and depression) remains to be tested.