CRISIS?
VAN WERT:
800-567-4673
PAULDING:
800-567-4673
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CRISIS?
CALL:
VAN WERT:
800-567-4673
PAULDING:
800-567-4673
Health Assessment Test
NAME
*
First
Middle
Last
AGE
*
D.O.B.
*
Month
Day
Year
FAMILY DOCTOR & ADDRESS:
DATE OF LAST MEDICAL CHECK UP
Month
Day
Year
CURRENT GENERAL HEALTH
*
SELECT ONE
POOR
FAIR
GOOD
EXCELLENT
HEIGHT
*
WEIGHT
LIST HOSPITALIZATIONS
LIST ALL MEDICATIONS YOU ARE TAKING AND DOSAGE (include prescribed & over the counter medications; state frequency of use, and any instructions for use; and the prescribing physician’s name)
*
if you are not taking any medications put "none".
LIST ALL ALLERGIES I NCLUDING DRUG ALLERGIES
*
if you don't have any put "none".
MEDICAL HISTORY (PLEASE CHECK ALL THAT APPLY)
1. AIDS
2. Alcoholism
3. Anemia
4. Anorexia
5. Appendicitis
6. Arthritis
7. Asthma
8. Bleeding Disorders
9. Breast Lump
10. Bronchitis
11. Bulimia
12. Cancer
13. Cataracts
14. Chemical Dependency
15. Chicken Pox
16. Diabetes
17. Emphysema
18. Epilepsy
19. Glaucoma
20. Goiter
21. Gonorrhea
22. Gout
23. Heart Disease
24. Hepatitis
25. Hernia
26. Herpes
27. High Cholesterol
28. HIV Positive
29. Kidney Disease
30. Liver Disease
31. Measles
32. Migraine Headaches
33. Miscarriage
34. Mononucleosis
35. Multiple Sclerosis
36. Mumps
37. Pacemaker
38. Pneumonia
39. Polio
40. Prostate Problem
41. Psychiatric Care
42. Rheumatic Fever
43. Scarlet Fever
44. Stroke
45. Suicide Attempt
46. Thyroid Problems
47. Tonsillitis
48. Tuberculosis
49. Typhoid Fever
50. Ulcers
51. Vaginal Infections
52. Venereal Disease
WHICH OF THE ABOVE HAS AN IMMEDIATE FAMILY MEMBER HAD A HISTORY OF? (PLEASE LIST by #)
CURRENT PROBLEMS OR COMPLAINTS (PLEASE CHECK ALL THAT APPLY)
Back pain/chronic pain
Blood Pressure
Convulsions or Seizures
Dizzy Spells
Eating Problems
Fainting Spells
Frequent Headaches
Hearing Loss
Loss Of Appetite
Nausea or vomiting
Paralysis or weakness
Pregnancy
Problems with sleeping
Ringing in the ears
Unusual fatigue/tiredness
Are you pregnant?
*
Yes
No
Maybe
LMP
#Pregnancies
#Live Births
HABITS & HEALTH BEHAVIORS (PLEASE CHECK ALL THAT APPLY)
Alcohol
Other Drugs
Smoking
Coffee
Chronic or Constant Pain
Change in Nutrition or Eating Habits
Change in Sleep Pattern
Change in Exercise Behaviors
Present Alcohol Use
Light
Moderate
Heavy
Past Alcohol Use
Light
Moderate
Heavy
Type of Alcohol
Present Drug Use
Light
Moderate
Heavy
Past Drug Use
Light
Moderate
Heavy
Type of Drugs
Packs Per Day
Cups Per Day
Chronic or Constant Pain Level
Light
Modereate
Severe
Change in Sleep Pattern
Increased
Decreased
Interrupted
Change in Nutrition or Eating Habits
Increased
Decreased
Change in Exercise Behaviors
Increased
Decreased
REFERRED TO FAMILY PHYSICIAN FOR EVALUATION
Yes
No
Are you human?
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