Health Questionnaire Form - California

State of California Health and Human Services Agency Department of Health Care Services
Licensing and Certification Bran ch, M S 2600
PO Box 997413
Sacramento, CA 95899-7413
CLIENT HEALTH QUESTIONAIRE
HEALTH QUESTIONNAIRE SCORING KEY
This self-administered questionnaire is designed to provide programs with a set of general guidelines to assist in determining an
individual’s suitability for treatment/recovery services in a non-medical facility. It is intended as a guideline only and should
not be substituted for common sense or any other available data which contradicts this questionnaire. When in doubt, always
consider the severity of the issue and, above all, the well-being of the client. The potential value of a thorough Health Screening
administered by a nurse practitioner or physician should never be underestimated.
The high incidence of illness at time of admission to a program calls for caution and attention to detail. No client can benefit
from
a program if he or she is too ill to participate fully. Conversely, no program can succeed if its clients are unable to
utilize the
services offered.
Section 1
A yes answer to any of the questions in section 1 indicates the existence of a potentially life threatening condition. You
should
strongly consider referring the individual to a qualified physician, requesting that they provide you with a medical
clearance to
participate in a program. Enrollment in the program prior to receiving a medical clearance is at the discretion of
the program.
Section 2
A yes answer to any of the questions in section 2 indicates the existence of a serious health condition. Although admission
into
your program may be appropriate, a thorough Health Screening should be scheduled at the time of admission.
Continuing
participation in the program should be at the discretion of program.
Section 3
A yes answer to any of the questions in section 3 does not necessarily indicate the existence of a serious health
condition.
However, multiple yes answers could be cause for concern and indicative of a generally poor health condition.
Multiple yes
answers in section 3 may warrant a Health Screening. At a minimum information gathered in section 3 should
be available to
staff in order to better serve the client.
DHCS 5103 (07/13) Page 1 of 4
Page 1/4
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