Adult Health Risk Assessment Questionnaire

Please correct the errors described below.

Pain Assessment

*please select current pain level if applicable in the pain scale shown below*

Exercise Frequency

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Depression Screening-PHQ9

Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 = Not at all | 1 = Several Days | 2 = More than half the days | 3 = Nearly everyday

Alcohol Assessment

If yes, please answer the following questions below. Thank you!

C.A.G.E

Habit Assessment

Tobacco(chew, cigar, pipe, cigarette)

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TB Risk Assessment

In the past 2 years….

** TB test is needed if the answer is YES to any of the above questions. Proceed with office protocol at that point. If the answer is NO then no further action is required.

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