Fillable Printable Health Questionnaire Form - California
Fillable Printable Health Questionnaire Form - California
Health Questionnaire Form - California
State of California — Health and Human Services Agency Department of Health Care Services
Licensing and Certification Bran ch, M S 2600
PO Box 997413
Sacramento, CA 95899-7413
CLIENT HEALTH QUESTIONAIRE
HEALTH QUESTIONNAIRE SCORING KEY
This self-administered questionnaire is designed to provide programs with a set of general guidelines to assist in determining an
individual’s suitability for treatment/recovery services in a non-medical facility. It is intended as a guideline only and should
not be substituted for common sense or any other available data which contradicts this questionnaire. When in doubt, always
consider the severity of the issue and, above all, the well-being of the client. The potential value of a thorough Health Screening
administered by a nurse practitioner or physician should never be underestimated.
The high incidence of illness at time of admission to a program calls for caution and attention to detail. No client can benefit
from
a program if he or she is too ill to participate fully. Conversely, no program can succeed if its clients are unable to
utilize the
services offered.
Section 1
A yes answer to any of the questions in section 1 indicates the existence of a potentially life threatening condition. You
should
strongly consider referring the individual to a qualified physician, requesting that they provide you with a medical
clearance to
participate in a program. Enrollment in the program prior to receiving a medical clearance is at the discretion of
the program.
Section 2
A yes answer to any of the questions in section 2 indicates the existence of a serious health condition. Although admission
into
your program may be appropriate, a thorough Health Screening should be scheduled at the time of admission.
Continuing
participation in the program should be at the discretion of program.
Section 3
A yes answer to any of the questions in section 3 does not necessarily indicate the existence of a serious health
condition.
However, multiple yes answers could be cause for concern and indicative of a generally poor health condition.
Multiple yes
answers in section 3 may warrant a Health Screening. At a minimum information gathered in section 3 should
be available to
staff in order to better serve the client.
DHCS 5103 (07/13) Page 1 of 4
State of California — Health and Human Services Agency Department of Health Care Services
Licensing and Certification Bran ch, M S 2600
PO Box 997413
Sacramento, CA 95899-7413
CLIENT HEALTH QUESTIONAIRE
Name: Date of Birth: _
Date:
This brief questionnaire is about your health. It will assist us in determining your ability to participate in our program. This
information is confidential.
Section 1
1.
Do you have any serious health problems or illnesses (such as tuberculosis or active pneumonia) that may be contagious
to others around you? If yes, please give details.
No Yes Date:
Details: _
2.
Have you ever had a stroke? If yes, please give details.
No Yes Date:
Details: _
3.
Have you ever had a head injury that resulted in a period of loss of consciousness? If yes,
please give details.
No Yes Date:
Details: _
4.
Have you ever had any form of seizures, delirium tremens or convulsions? If yes, please give details.
No Yes Date:
Details: _
5.
Have you experienced or suffered any chest pains? If yes, please give details.
No Yes Date:
Details: _
Section 2
6.
Have you ever had a heart attack or any problem associated with the heart? If yes, please give details.
No Yes Date:
Details: _
7.
Do you take any medications for a heart condition? If yes, please give details.
No Yes Date:
Details: _
8.
Have you ever had blood clots in the legs or elsewhere that required medical attention? If yes, please give details.
No Yes Date:
Details: _
9.
Have you ever had high-blood pressure or hypertension? If yes, please give details.
No Yes Date:
Details: _
10.
Do you have a history of cancer? If yes, please give details.
No Yes Date:
Details: _
11.
Do you have a history of any other illness that may require frequent medical attention? If yes, please give details.
No Yes Date:
Details:
Page 2 of 4
DHCS 5103 (07/13)
State of California — Health and Human Services Agency Department of Health Care Services
Licensing and Certification Bran ch, M S 2600
PO Box 997413
Sacramento, CA 95899-7413
CLIENT HEALTH QUESTIONAIRE
Section 3
12.
Do you have any allergies to medications, foods, animals, chemicals, or any other substance. If yes, please give details.
No Yes Date:
Details:
13.
Have you ever had an ulcer, gallstones, internal bleeding, or any type of bowel or colon inflammation? If yes, please give
details.
No Yes Date:
Details:
14.
Have you ever been diagnosed with diabetes? If yes, please give details, including insulin, oral medications, or special diet.
No Yes Date:
Details: _
15.
Have you ever been diagnosed with any type of hepatitis or other liver illness? If yes, please give details.
No Yes Date:
Details: _
16.
Have you ever been told you had problems with your thyroid gland, been treated for, or told you need to be treated for, any
other type of glandular disease? If yes, please give details.
No Yes Date:
Details: _
17.
Do you currently have any lung diseases such as asthma, emphysema, or chronic bronchitis? If yes, please give details.
No Yes Date:
Details: _
18.
Have you ever had kidney stones or kidney infections, or had problems, or been told you have problems with your kidneys
or bladder. If yes, please give details.
No Yes Date:
Details: _
19.
Do you have any of the following; arthritis, back problems, bone injuries, muscle injuries, or joint injuries? If yes, please give
details, including any ongoing pain or disabilities.
No Yes Date:
Details: _
20.
Please describe any surgeries or hospitalizations due to illness or injury that you have had.
Date:
21.
When was the last time you saw a physician? What was the purpose of the visit?
Date:
_
22.
Do you take any prescription medications including psychiatric medications? If yes, please list type(s) and dosage(s).
No Yes Details:
23.
Do you take over the counter pain medications such as aspirin, Tylenol, or Ibuprofen? If yes, list the medication(s) and how
often you take it.
No Yes Details:
Page 3 of 4
DHCS 5103 (07/13)
State of California — Health and Human Services Agency Department of Health Care Services
Licensing and Certification Bran ch, M S 2600
PO Box 997413
Sacramento, CA 95899-7413
CLIENT HEALTH QUESTIONAIRE
24.
Do you take over the counter digestive medications such as Tums or Maalox? If yes, list the medication(s) and how often
you take it.
No Yes Details:
25.
Do you wear or need to wear glasses, contact lenses, or hearing aids? If yes, please give details.
No Yes Details:
26.
When was your last dental exam? Date: _ _
27.
Are you in need of dental care? If yes, please give details.
No Yes Details:
28.
Do you wear or need to wear dentures or other dental appliances that may require dental care? If yes, please give details.
No Yes Details:
29.
Are you pregnant?
No Yes Due Date:
30.
In the past seven days what types of drugs, including alcohol, have you used?
Type of Drug
Route of Administration
31.
In the past year what types of drugs, including alcohol, have you used?
Type of Drug
Route of Administration
I declare that the above information is true and correct to the best of my knowledge:
Client Signature: Today’s Date:
Reviewing Facility/Program Staff Name:
Reviewing Facility/Program Staff Signature: Date:
Page 4 of 4
DHCS 5103 (07/13)
