Sr. Health Risk Assessment Questionnaire

Please correct the errors described below.

Functional Evaluation

Home Safety Assessment

Hearing Assessment

Balance Assessment

Pain Assessment

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

How intense is your typical exercise? (Check one)

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!

Habit Assessment

Tobacco (Chew, Cigar, Pipe, Cigarette)

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. **

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.

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

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