Table 2.

The Physician’s Questionnaire (PQ)

Child Somatization: Primary Care Physician’s Form
Child’s Name
Chart #
1. Was this visit solely for a regular checkup?
Yes □
No □
2. Do you think this child should be kept away from school or other daily activities?
Major restrictions	No restrictions
1- - - - - - - - -2- - - - - - - - -3- - - - - - - - -4- - - - - - - - -5- - - - - - - - -6- - - - - - - - -7
3. Do you think this child’s health should be monitored closely in the immediate future?
Extremely closely	Not exceptionally closely
1- - - - - - - - -2- - - - - - - - -3- - - - - - - - -4- - - - - - - - -5- - - - - - - - -6- - - - - - - - -7
4. Do you recommend a follow-up visit?
Highly recommended	Not needed
1- - - - - - - - -2- - - - - - - - -3- - - - - - - - -4- - - - - - - - -5- - - - - - - - -6- - - - - - - - -7