Health Questionnaire

  • Health Questionnaire

    Neighbors Caring for Neighbors
  • Date of Birth
     / /
  • Date of Birth
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  • MEDICAL HISTORY

  • Have you been diagnosed with any of the following conditions? If so, please list the providers name in the provided space below.
  • Rows

  • SOCIAL HISTORY

  • Do you currently use any of the following?
  • Would you like help quitting?
  • Are you a former smoker/smokeless tobacco user?

  • If you are under the age of 18, please skip the following sections. Scroll to the bottom and click "Submit" Patients 18 and over please complete the following questions and then click "Submit".

  • CAGE-AID Questionnaire

    If you are age 18 and above, please complete this section. Skip this section if you are under age 18.
  • Do you drink alcohol?
  • Do you use illegal drugs?

  • If yes, please answer the following questIons.

    When thinking about drug use, include illegal drug use and the use of prescription drug use other than prescribed.

  • Have you ever thought you ought to cut down on your drinking?
  • Have people annoyed you by criticizing your drinking or drug use?
  • Have you ever felt bad or guilty about your drinking or drug use?
  • Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover?

  • PC-PTSD-5

  • Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic.  For example:

    • a serious accident or fire
    • a physical or sexual assault of abuse
    • an earthquake or flood
    • a war
    • seeing someone be killed or seriously injured
    • having a loved one die through homicide or suicide

  • Have you ever experienced this kind of event?

  • If yes, please answer the following questions. In the past month, have you experienced any of the following?

  • Had nightmares about event(s) or thought about the event(s) when you did not want to?
  • Tried hard not to think about the event(s) or went our of your way to avoid situations that reminded you of the event(s)?
  • Been constantly on guard, watchful, or easily startled?
  • Felt numb or detached from people, activities, or your surroundings?
  • Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?

  • GAD-7

  • Over the last two weeks, how often have you been bothered by any of the following problems?

     

  • Rows
  • If you checked any of the previous problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people? (choose one)
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  • Should be Empty: