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
Name: Date of Birth: _
Date:
This brief questionnaire is about your health. It will assist us in determining your ability to participate in our program. This
information is confidential.
Section 1
1.
Do you have any serious health problems or illnesses (such as tuberculosis or active pneumonia) that may be contagious
to others around you? If yes, please give details.
No Yes Date:
Details: _
2.
Have you ever had a stroke? If yes, please give details.
No Yes Date:
Details: _
3.
Have you ever had a head injury that resulted in a period of loss of consciousness? If yes,
please give details.
No Yes Date:
Details: _
4.
Have you ever had any form of seizures, delirium tremens or convulsions? If yes, please give details.
No Yes Date:
Details: _
5.
Have you experienced or suffered any chest pains? If yes, please give details.
No Yes Date:
Details: _
Section 2
6.
Have you ever had a heart attack or any problem associated with the heart? If yes, please give details.
No Yes Date:
Details: _
7.
Do you take any medications for a heart condition? If yes, please give details.
No Yes Date:
Details: _
8.
Have you ever had blood clots in the legs or elsewhere that required medical attention? If yes, please give details.
No Yes Date:
Details: _
9.
Have you ever had high-blood pressure or hypertension? If yes, please give details.
No Yes Date:
Details: _
10.
Do you have a history of cancer? If yes, please give details.
No Yes Date:
Details: _
11.
Do you have a history of any other illness that may require frequent medical attention? If yes, please give details.
No Yes Date:
Details:
Page 2 of 4
DHCS 5103 (07/13)
Page 2/4
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