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
24.
Do you take over the counter digestive medications such as Tums or Maalox? If yes, list the medication(s) and how often
you take it.
No Yes Details:
25.
Do you wear or need to wear glasses, contact lenses, or hearing aids? If yes, please give details.
No Yes Details:
26.
When was your last dental exam? Date: _ _
27.
Are you in need of dental care? If yes, please give details.
No Yes Details:
28.
Do you wear or need to wear dentures or other dental appliances that may require dental care? If yes, please give details.
No Yes Details:
29.
Are you pregnant?
No Yes Due Date:
30.
In the past seven days what types of drugs, including alcohol, have you used?
Type of Drug
Route of Administration
31.
In the past year what types of drugs, including alcohol, have you used?
Type of Drug
Route of Administration
I declare that the above information is true and correct to the best of my knowledge:
Client Signature: Todays Date:
Reviewing Facility/Program Staff Name:
Reviewing Facility/Program Staff Signature: Date:
Page 4 of 4
DHCS 5103 (07/13)
Page 4/4
Free Download

Health Questionnaire Form - California PDF

Favor this template? Just fancy it by voting!
  •  
  •  
  •  
  •  
  •  
(0 Votes)
0.0
Related Forms
  •  
  •  
  •  
  •  
  •  
1 Page(s) | 655 Views | 1 Downloads
  •  
  •  
  •  
  •  
  •  
1 Page(s) | 2898 Views | 162 Downloads
  •  
  •  
  •  
  •  
  •  
2 Page(s) | 1461 Views | 16 Downloads
  •  
  •  
  •  
  •  
  •  
2 Page(s) | 1089 Views | 3 Downloads