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
Section 3
12.
Do you have any allergies to medications, foods, animals, chemicals, or any other substance. If yes, please give details.
No Yes Date:
Details:
13.
Have you ever had an ulcer, gallstones, internal bleeding, or any type of bowel or colon inflammation? If yes, please give
details.
No Yes Date:
Details:
14.
Have you ever been diagnosed with diabetes? If yes, please give details, including insulin, oral medications, or special diet.
No Yes Date:
Details: _
15.
Have you ever been diagnosed with any type of hepatitis or other liver illness? If yes, please give details.
No Yes Date:
Details: _
16.
Have you ever been told you had problems with your thyroid gland, been treated for, or told you need to be treated for, any
other type of glandular disease? If yes, please give details.
No Yes Date:
Details: _
17.
Do you currently have any lung diseases such as asthma, emphysema, or chronic bronchitis? If yes, please give details.
No Yes Date:
Details: _
18.
Have you ever had kidney stones or kidney infections, or had problems, or been told you have problems with your kidneys
or bladder. If yes, please give details.
No Yes Date:
Details: _
19.
Do you have any of the following; arthritis, back problems, bone injuries, muscle injuries, or joint injuries? If yes, please give
details, including any ongoing pain or disabilities.
No Yes Date:
Details: _
20.
Please describe any surgeries or hospitalizations due to illness or injury that you have had.
Date:
21.
When was the last time you saw a physician? What was the purpose of the visit?
Date:
_
22.
Do you take any prescription medications including psychiatric medications? If yes, please list type(s) and dosage(s).
No Yes Details:
23.
Do you take over the counter pain medications such as aspirin, Tylenol, or Ibuprofen? If yes, list the medication(s) and how
often you take it.
No Yes Details:
Page 3 of 4
DHCS 5103 (07/13)
Page 3/4
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