Sr. Health Risk Assessment Questionnaire

Date:

Patient Name:

Date of Birth:

In general would you say your health is

Excellent Very Good Good Fair Poor

Functional Evaluation

Do you live alone?

Yes No

If No who do you live with?

Home Safety Assessment

Do you have easy access to a phone at home?

Yes No

Do you have a functioning carbon monoxide alarm in your home?

Yes No

Do you have a functioning smoke alarm in your home?

Yes No

Hearing Assessment

Do you have trouble hearing the television or radio when others do not?

Yes No

Do you have to strain or struggle to hear or understand conversations?

Yes No

Balance Assessment

Have you fallen in the past year?

Yes No

If Yes, how many times?

1 > 2

Pain Assessment

How often have you had pain during the past 3 months?

not at all some days most days every day

How often during the past 3 months has pain kept you from doing activities you enjoy?

not at all some days most days every day

Please select your current pain level with 0 being No Pain and 10 being Worst Pain

How intense is your typical exercise? (Check one)

I am currently not exercising

Light (like stretching or slow walking)

Moderate (like brisk walking)

Heavy (like jogging or swimming)

Very heavy (like fast running or stair climbing)

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

*Little interest or pleasure in doing things you once enjoyed

*Feeling down, depressed or hopeless

*Trouble falling or staying asleep, or sleeping too much

*Feeling tired or having little energy

*Poor appetite or overeating

*Feeling bad about yourself-or that you are a failure or have let yourself or your family down

*Trouble concentrating on things, such as reading the newspaper or watching television

*Moving or speaking so slowly that other people could have noticed, or the opposite- being so fidgety or restless, and you are moving around more than usual

*Thoughts that you would be better off dead, or thoughts of hurting yourself in some way

PHQ-9 SCORE

C.A.G.E

Alcohol Assessment

Do you consume alcohol?

Yes No

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

C - Have you ever felt you should cut down on your drinking?

Yes No

A - Have people annoyed you by criticizing your drinking?

Yes No

G- Have you ever felt bad or guilty about your drinking?

Yes No

E- Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? (Eye opener)

Yes No

Habit Assessment

Tobacco (Chew, Cigar, Pipe, Cigarette)

Do you use tobacco products now or in the past?

Yes No

Number of years:

Number of packs per day:

Former Smoker Quit Date

Nicotine (Vape):

Never Current Former

Recreational Drugs

Never Current Social/Occasional

If current, what drug(s)?

If former user, what drugs?

TB Risk Assessment

Do you currently have any of the following symptoms:

Prolonged Cough >3 weeks

Coughing Up Blood

Unexplained Weight Loss

Chronic Fever

Drenching Night Sweats

N/A

In the past 2 years….

Have you had any contact with someone with known TB disease of the lung?

Yes No

Spent more than 2 weeks in Asia, Africa, Latin America or Eastern Europe?

Yes No

Been in prison or jail?

Yes No

Been homeless?

Yes No

Inject street drugs?

Yes No

Worked with homeless persons, migrant works or drug users?

Yes No

Worked as a healthcare worker?

Yes No

** 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. **

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.

PATIENT NAME/SIGNATURE:

PROVIDER NAME/SIGNATURE:

1377 S. Grand Ave Glendora, CA 91740 Phone 626-483-3348 Fax 626-623-7258
Sept 2019 VERSION 2.0

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