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

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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)

werwer
werwer

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your message will be encrypted.