Treating Somatization: A Cognitive-Behavioral Approach (Robert L.

Woolfolk;Lesley A. Allen)

Somatic Symptom Questionnaire

From Robert L. Woolfolk and Lesley A. Allen. Copyright 2007 by The
Guilford Press. Permission to photocopy this appendix is granted to
purchasers of this book for personal use only (see copyright page for
details).
We would like you to tell us about some physical symptoms people often
experience. By marking "Yes" or "No" in the blanks after the following
statements, indicate whether you have experienced the symptom
described in the statement. If you have never experienced the symptom
described in part A of the question, skip sections B-D of that item
and go to the next numbered question. If you have experienced the
symptom described in part A of the question, please answer parts B-D.
If the symptom was entirely due to a physical illness or an accident,
please indicate so in the space provided after the statement. Also,
please indicate whether you consulted a doctor for this symptom. If
you received a diagnosis as a result of the consultation, please write
the diagnosis in the blank provided.
1. A) Have you ever had a lot of trouble with abdominal or belly pain
(not counting times you were menstruating)? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

2.A) Have you ever had a lot of trouble with back pain? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

3. A) Have you ever had pains in your joints (knees, elbows, etc.)?
Yes
No

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Treating Somatization: A Cognitive-Behavioral Approach (Robert L.

Woolfolk;Lesley A. Allen)
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

4. A) Have you ever had pains in your arms and legs other than joint
pains? Yes No
B) If yes, was the symptom due to a physical illness or an accident?
Yes

No

C) Have you seen a doctor for that syndrom? Yes No

D) If yes, what was the doctor's diagnosis?

5. A) Have you ever had chest pains? Yes No

B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

6. A) Have you ever had a lot of trouble with headaches ? Yes No

B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

7. A) Have you ever had a lot of trouble with excessively painful

menstrual periods? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
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Treating Somatization: A Cognitive-Behavioral Approach (Robert L.

Woolfolk;Lesley A. Allen)
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

8. A) Have you ever had pain when you urinated-that is passed your
water?Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

9. A) Has there ever been a time lasting 24 hours or longer when you
where completely unable to urinate or had great difficulty urinating
(other than after childbirth or surgery)? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

10. A) Have you ever had burning pain in your "private parts"? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

11. A) Have you ever had other pain, pain not described in questions 1
- 10? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
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Treating Somatization: A Cognitive-Behavioral Approach (Robert L.

Woolfolk;Lesley A. Allen)
D) If yes, what was the doctor's diagnosis?

12. A) Have you ever had a lot of trouble with excessive vomiting, at
times other than during pregnancy? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

13. A) During any pregnancy, did you vomit all through the pregnancy?
Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

14. A) Have you ever had a lot of trouble with nausea (feeling sick to
your stomach but not actually vomiting)? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

15. A) Have you ever had a lot of trouble with loose bowels or
diarhhea?
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?
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Treating Somatization: A Cognitive-Behavioral Approach (Robert L.

Woolfolk;Lesley A. Allen)

16. A) Have you ever had a lot of trouble with excessive gas or
bloating of your stomach or abdomen? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

17. A) Have you ever found there were several kinds of food that you
couldn't eat because they made you ill? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

18. A) Have you ever lost your vision in one or both to the extent
that you couldn't see anything at all for a few second or more? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

19. A) Has your vision ever become blur for some period (not including
times when you needed glasses or a change in your glasses)? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

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Treating Somatization: A Cognitive-Behavioral Approach (Robert L.

Woolfolk;Lesley A. Allen)
20. A) Have you ever lost your hearing for a period of time? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

21. A) Have you ever had trouble walking? Yes No

B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

22. A) Have you ever lost feeling in an arm or a leg (at times other
than when it had fallen asleep or become numb from being in one
position too long)? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

23. A) Have you ever been completely unable to move a part of your
body for at least a few minutes? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

24. A)Have you ever lost your voice for 30 minutes or more so that you
couldn't speak above a whisper? Yes No
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Treating Somatization: A Cognitive-Behavioral Approach (Robert L.

Woolfolk;Lesley A. Allen)
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

25. A) During the time since your 12th birthday, have you ever had a
seizure or a convulsion that caused you to become unconcious or caused
your body to jerk uncontrollably? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

26. A) Have you ever had fainting (or falling out) spells where you
felt weak or dizzzy then passed out? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

27. A) Have you ever been unconcious for any other reason? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

28. A) Have you ever had a period of amnesia-that is, a period of

several hours or days when you couldn't remember anything afterwards
about what had happen during that time? Yes No

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Treating Somatization: A Cognitive-Behavioral Approach (Robert L.

Woolfolk;Lesley A. Allen)
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

29. A) Have you ever had problems with double vision? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

30. A) Have you ever had shortness of breath when you had not been
exercising or exerting yourself? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

31. A) Has your heart ever beat so hard that you could feel it pound
in your chest? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

32. A) Have you ever been bothered by dizziness? Yes No

B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
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Treating Somatization: A Cognitive-Behavioral Approach (Robert L.

Woolfolk;Lesley A. Allen)
D) If yes, what was the doctor's diagnosis?

33. A) Have you ever been bothered by periods of weakness-that is,

when you could not lift or move thing you could normally lift or move?
Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

34. A) Have you ever been bothered a lot by blotchiness or

discoloration of the skin? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

35. A) Did you ever had a lot of trouble with a bad taste in your
mouth or an excessive coated tongue? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

36. A) Did having to urinate too frequently ever caused you a lot of
trouble? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No

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Treating Somatization: A Cognitive-Behavioral Approach (Robert L.

Woolfolk;Lesley A. Allen)
D) If yes, what was the doctor's diagnosis?

37. A) Have you ever been bothered a lot by unpleasant numbness or

tingling sensations? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

38. A) Have you ever felt as though there were a lump in your throat
that made it difficult to swallow? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

39. A) Other than your first year of menstruation, have your menstrual
periods ever been irregular? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?

40. A) Have you ever had excessive bleeding with your menstrual
periods? Yes No
B) If yes, was that symptom due to a physical illness or an accident?
Yes
No
C) Have you seen a doctor for that symptom? Yes No
D) If yes, what was the doctor's diagnosis?
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Treating Somatization: A Cognitive-Behavioral Approach (Robert L.

Woolfolk;Lesley A. Allen)

How old were you when you were first bothered by symptoms described in
items 1-40? Age first bothered:

How old were you when you were last bothered by symptoms such as those
described in items 1-40? Age last bothered:

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