Fillable Printable Health Questionnaire Form - California
Fillable Printable Health Questionnaire Form - California
Health Questionnaire Form - California
Stateof California— Health and Human Services AgencyDepartment of Health Care Services
Licensing and Certification Bran ch, M S 2600
POBox 997413
Sacramento, CA 95899-7413
CLIENT HEALTH QUESTIONAIRE
HEALTH QUESTIONNAIRE SCORINGKEY
This self-administered questionnaireis designed to provide programs with a set ofgeneral guidelines toassistin determining an
individual’s suitabilityfortreatment/recoveryservices in a non-medical facility. It is intended as a guideline only and should
not be substituted for common senseor anyother available data which contradictsthisquestionnaire. When in doubt, always
consider the severityofthe issue and, above all,the well-being ofthe client. The potential valueofathorough Health Screening
administered bya nurse practitioner orphysician should never be underestimated.
The high incidence of illness at time of admission to a programcalls for cautionand attention to detail. Noclient can benefit
from
a program if he or she is too ill to participate fully. Conversely, no program can succeed ifits clientsareunable to
utilize the
services offered.
Section1
A yes answer to anyof the questions in section 1 indicates the existence ofa potentially life threatening condition. You
should
strongly consider referring the individual toa qualified physician, requesting that they provide you with a medical
clearance to
participate in a program. Enrollment in the programprior to receiving a medicalclearance is at the discretion of
the program.
Section2
A yes answerto any of the questions in section 2indicates the existence ofa serious health condition. Although admission
into
your program maybe appropriate, a thorough Health Screeningshould be scheduled at the time ofadmission.
Continuing
participation in the program should be at the discretion of program.
Section3
A yes answerto anyofthe questions in section 3 doesnot necessarily indicate the existence ofa serious health
condition.
However,multipleyes answerscouldbe cause for concernand indicativeof a generallypoor health condition.
Multipleyes
answersin section 3 maywarrant a Health Screening. At aminimuminformation gathered in section 3 should
be available to
staff in order tobetter servetheclient.
DHCS 5103 (07/13)Page 1 of 4
Stateof California— Health and Human Services AgencyDepartment of Health Care Services
Licensing and Certification Bran ch, M S 2600
POBox 997413
Sacramento, CA 95899-7413
CLIENT HEALTH QUESTIONAIRE
Name:Date of Birth: _
Date:
This brief questionnaireis about your health. It will assist usin determining your abilityto participate in our program. This
information is confidential.
Section1
1.
Doyou have any serious health problems or illnesses (such astuberculosis or active pneumonia) that maybe contagious
to othersaround you?If yes, please give details.
NoYesDate:
Details:_
2.
Have you ever had a stroke? If yes, please give details.
NoYesDate:
Details:_
3.
Have you ever had a head injurythatresulted in a period of loss of consciousness? If yes,
please give details.
NoYesDate:
Details:_
4.
Have you ever had any form ofseizures, delirium tremensor convulsions?If yes, please give details.
NoYesDate:
Details:_
5.
Have you experienced or suffered anychest pains? If yes, please give details.
NoYesDate:
Details:_
Section2
6.
Have you ever had a heartattack or anyproblem associated with the heart? If yes, pleasegive details.
No YesDate:
Details:_
7.
Do youtake anymedications for a heartcondition? If yes, please give details.
No YesDate:
Details:_
8.
Have you ever had blood clots in the legs or elsewherethat required medical attention? If yes, please give details.
No YesDate:
Details:_
9.
Have you ever hadhigh-blood pressureorhypertension? If yes, please give details.
No YesDate:
Details:_
10.
Do you have ahistory ofcancer?If yes, please give details.
No YesDate:
Details: _
11.
Do you havea history ofany otherillnessthat may requirefrequent medical attention? If yes, please give details.
No YesDate:
Details:
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DHCS5103 (07/13)
Stateof California— Health and Human Services AgencyDepartment of Health Care Services
Licensing and Certification Bran ch, M S 2600
POBox 997413
Sacramento, CA 95899-7413
CLIENT HEALTH QUESTIONAIRE
Section3
12.
Doyou have anyallergies to medications, foods, animals, chemicals, oranyother substance. If yes, please givedetails.
No YesDate:
Details:
13.
Have you ever had an ulcer, gallstones, internalbleeding, or anytypeof bowel or colon inflammation? If yes, please give
details.
No YesDate:
Details:
14.
Have you ever been diagnosed with diabetes? If yes, please give details, including insulin, oral medications, or special diet.
NoYesDate:
Details: _
15.
Have you ever been diagnosed with anytype ofhepatitis orother liver illness? If yes, pleasegive details.
No YesDate:
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 typeofglandular disease? If yes, please givedetails.
No YesDate:
Details: _
17.
Do youcurrently have any lung diseases such asasthma, emphysema, or chronicbronchitis? If yes, pleasegive details.
No YesDate:
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,pleasegive details.
No YesDate:
Details: _
19.
Do you have anyofthe following; arthritis, back problems, bone injuries, muscle injuries, or joint injuries? If yes, please give
details, includingany ongoing pain or disabilities.
No YesDate:
Details: _
20.
Please describeany surgeries or hospitalizations due to illness or injurythat you havehad.
Date:
21.
When was the last time you saw aphysician? What was the purpose of thevisit?
Date:
_
22.
Doyoutake any prescription medications includingpsychiatric medications? If yes, please list type(s) and dosage(s).
No YesDetails:
23.
Do youtake overthecounter pain medications such as aspirin, Tylenol, or Ibuprofen? If yes, list the medication(s) and how
often you take it.
NoYesDetails:
Page 3of 4
DHCS5103 (07/13)
Stateof California— Health and Human Services AgencyDepartment of Health Care Services
Licensing and Certification Bran ch, M S 2600
POBox 997413
Sacramento, CA 95899-7413
CLIENT HEALTH QUESTIONAIRE
24.
Do youtake overthecounter digestivemedications such as Tumsor Maalox? If yes, list the medication(s) and how often
you take it.
NoYesDetails:
25.
Do you wear or need towear glasses, contact lenses, or hearing aids? If yes, please givedetails.
No YesDetails:
26.
When wasyour last dental exam? Date: _ _
27.
Are youin need ofdental care? If yes, please give details.
No YesDetails:
28.
Do youwear or need toweardentures or other dental appliances that mayrequiredental care? If yes, please give details.
No YesDetails:
29.
Areyoupregnant?
No YesDue Date:
30.
In the past sevendays what types of drugs, including alcohol, have you used?
Type ofDrug
Route ofAdministration
31.
In the past year what types ofdrugs, including alcohol, have you used?
Type ofDrug
Route ofAdministration
I declare that theabove informationis trueandcorrect tothebest ofmy knowledge:
Client Signature: Today’s Date:
Reviewing Facility/ProgramStaff Name:
Reviewing Facility/Program Staff Signature:Date:
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DHCS5103 (07/13)
