HEALTH RISK ASSESSMENT QUESTIONNAIRE



Magnolia Family Medicine Phone: 910-796-3212 Fax: 910-796-3216 ANNUAL WELLNESS/HEALTH ASSESSMENT VISITS Today’s Date:_________ Your Full Name: __________________________________ Date of Birth ____________Street Address:___________________________________________________________Street City Zip Code Phone Numbers:_______________________Email: ___________________________Please check the box that answers the questions below and write any additional information that will help us meet your needs better. Please, No Blank Answers.1.What is your natural language? □ English □ Spanish Other: _________________2. A. Where do you currently live?□Independent house, apartment, mobile home□Assisted Living Apartment, or board & care Name: ___________________□Nursing home Name: ____________________________________________B. Do you OWN or RENT? (please circle)3.What is your current living arrangement? (check each that applies) □Live Alone□With other relative(s)□With spouse/significant other□With non-relative(s)□With child(ren)□With paid caregiver4.A. Are your parents alive/health condition? _________________________________B. Do you have children? □ Yes □ No #________ If yes, are they alive? __________5.A. Do you plan on changing your present living arrangements in the next 6 months?□ Yes □ No Describe_________________________________________________B. Do you feel safe in your neighborhood? □ Yes □ No ____________________6.Have you seen your current (Primary Care Physician) PCP in the last 3 months? □ No □ Yes Who is it? ______________________________________________________7.Are you under the care of any Specialist, if yes NAME & SPECIALTY? □ No□ Yes Names/Specialties_______________________________________________8.A. WHO is your Dentist and WHEN was the last time you went? ________________B. Circle: if you FLOSS/BRUSH C. Frequency: 1xday, 2xday, Weekly, Monthly, Never9.Have you been treated at the Emergency Room in the past 6 months? □ No□ Yes, number of times: ______ Why?_____________________________________ 10.Have you stayed overnight in a hospital in the past 12 months? □ No□ Yes, number of times: _______ Why?:_________________________________ 11.Have you been in a Skilled Nursing Facility in the past 12 months? □ No□ Yes, number of times: ______ Why?_____________________________________12.Do you have any wounds, sores or skin breakdown? □ No□ Yes Describe________________________________________________________13.In general, would you say your health is: (Check one answer) □ Excellent □ Very Good □ Good □ Fair □ Poor14.Do you smoke or use tobacco products? □ Yes □ No Type __________________14A.If YES, are you interested in a Smoking Cessation Program? □ Yes □ No15.A. Are you a former smoker? □ Yes □ No Year Started _______ Year Quit________ B. Chew? □ Yes □ No C. Using ECig? □ Yes □ No 16.Do you feel you have a problem with: A. → ALCOHOL □ Yes □ No OR B. → DRUG ABUSE □ Yes □ No How often do you drink alcohol? _________________EX: 1-2 drinks, 3x a wk17.Have you had sex in the past 12 months? □ Yes □ No 17a. Please circle: vaginal, oral, or anal 17b. With: □ Men only □ Women Only □ Both Men and Women17c. Use Protection? □ Yes □ No TYPE OF PROTECTION _________________17d. How many sexual partners have you had in your lifetime?_________________18.Have you ever had a Sexually Transmitted Disease? □ Yes □No If NO,skip to #19Chlamydia □ Yes □ No HPV □ Yes □ No HSVI □ Yes □ No HSVII □ Yes □ No Syphilis□ Yes □ No GC □ Yes □ No Trichomoniasis □ Yes □ NoOther _____________________________________________________________19.A. Experience sexual abuse? □No □Past □Now Do you feel safe now? □ Yes □ No B. Experience verbal abuse? □No □Past □Now Do you feel safe now? □ Yes □ No C. Experience physical abuse? □No □Past □Now Do you feel safe now? □ Yes □ No 20.Have you ever been treated for the following conditions? If yes, describe:□ Yes □ No Stroke ___________________________________________□ Yes □ No Heart Attack ______________________________________□ Yes □ No Chest Pain ________________________________________21.For each of the activities, indicate whether: can you do this without help or needs some help performing activity:NEEDS SOMEABLE TO DOHELPWITHOUT HELPUsing the toilet …………………… □ □ Bathing …………………………… □ □ Dressing ……………………………. □ □Eating ……………………………….. □ □Getting in/out of bed or chairs □ □Walking …………………………… □ □ Managing Money ………………….. □ □ Taking Medications ………………. □ □ Preparing Meals …………………… □ □ Shopping and Errands …………… □ □ Housekeeping Chores …………….. □ □ Using the Telephone………………. □ □ 22.If you receive help with any of the above activities, who helps? Circle: NO ONE or_____________________________________________________ □ Yes □ No Name Relationship Phone Number May we contact?23.A. How often do you see friends or family? Daily, Weekly, Monthly, Yearly, NeverB. Are you a member of any religious groups or organizations? □ Yes □ No 24.A. When do you have ANXIETY? Never Big Crowds Socially Work Other ________B. How much does anxiety affect your daily life? Always Often Sometimes Never25.Have you felt depressed in the last 3 months? □ Yes □ No If No, skip to #2625a. If YES, are you currently being treated for depression? □ Yes □ No25b. Do you want to discuss treatment options on your next appointment? Yes No26.Do you use any of the following special equipment because of a disability or health problem? Circle all that apply: 1. NONE 2. Grab Bars 3. Bedside Commode 4. Wheelchair 5. Ramps 6. Walker 7. Hospital Bed 8. Cane 9. Raised Toilet Seat 10. Hoyer Lift 27.CIRCLE if you currently use or receive any of the following? NONEFeeding Tube Colostomy Care Oxygen Catheter CPAP Other_______________ 28.Are you CURRENTLY being treated for any of the following health conditions?For any “YES” answer, please describe:□ Yes □ NoDialysis or Chronic Renal Failure ___________________________□ Yes □ NoMemory Loss___________________________________________□ Yes □ No Arthritis ______________________________________________ □ Yes □ NoUrinary Problems _______________________________________□ Yes □ NoBreathing Problems _____________________________________ □ Yes □ No High Blood Pressure ____________________________________□ Yes □ No Cancer ________________________________________________□ Yes □ No Circulation Problems ____________________________________□ Yes □ No Osteoporosis ___________________________________________ □ Yes □ NoStomach/Bowel Problems ________________________________□ Yes □ NoRecent Fracture (last 12 months) __________________________ □ Yes □ No Parkinson’s ____________________________________________□ Yes □ No Ankle/Leg Swelling or Edema ______________________________□ Yes □ NoUncorrected Hearing Loss ________________________________□ Yes □ No Congestive Heart Failure □ Yes □ No If you have Congestive Heart Failure, have you been hospitalized for it in the last 12 months? Other (Describe)_________________________________________________________29.Do you need help at home because of health problems □ Yes □ No 29a. Are you unable to get help? □ Yes □ No □ Not Applicable30.Are you currently receiving any of the following services from an agency?□ Yes □ No Home Health Nurse□ Yes □ No Home Health Aide□ Yes □ No Social Worker□ Yes □ No Adult Day Care Center□ Yes □ No Physical, Occupational, Speech Therapy at Home□ Yes □ No Transportation Assistance31.A. How is your eyesight? (While wearing glasses or contacts, if applicable) □ Excellent □ Good □ Fair □ Poor □ BlindB. Please circle if you wear lenses for: Reading Driving Never All the time32.Do you currently have any pain? □ Yes □ No If NO, go to question #3332a.Pain Severity Scale 1-10 (1 is less severe, 10 is most severe) □ 1 □ 2 □ 3 □ 4 □ 5 □ 6 □ 7 □ 8 □ 9 □ 1032b.Do you take over the counter OR prescription medicine for pain? □ Yes □ NoIf YES, name of medicine _______________________________________32c.Does the pain medicine provide adequate relief of your pain?□ All the Time □ Most of the Time □ Some of the Time □ NeverIf YES, describe pain _______________________________________________________33.Have you fallen in the last 12 months? □ Yes □ No If NO, go to question #34 33a. If yes, how many times? ____________ Injury? _________________________33b. If yes, did you go to the hospital?_____________________________________34.Which of the following statements applies to your health? Check all that apply.□I stay in bed all or most of the time because of physical limitations□I stay in the house all or most of the time because of physical limitations□Need help from another person in getting around inside or outside the house□I do not need help or special aid, but have trouble getting around freely□I’m not limited in any way35.Do you have Diabetes? □ Yes □ No If NO, go to question #36 35a. If Yes, have you had a Diabetic Eye Exam done in the past year?□ Yes □ No/Don’t know PLACE__________________________________35b.Have you had a Glaucoma (Eye Pressure) Screen done in the past year?□ Yes □ No/Don’t Know PLACE _________________________________36.Do you get a FLU SHOT every year? □ Yes □ No Where?__________When?_______37.Ever had a PNEUMONIA shot? □ Yes □ No □ Unknown Where?_____ When? ______38.Have you ever had a ZOSTAVAX shot (shingles vaccine)? □ Yes □ No □ Unknown39.How would you describe your ease to pay bills?□ Very Easy □ Easy □ Difficult □ Somewhat Difficult □ Nearly Impossible40.An Advance Directive defines your health care wishes in the event you become ill.Have you completed an Advance Directive? □ Yes □ No40a. If NO, are you interested in receiving information □ Yes □ No40b. If YES, is it on file with your PCP? □ Yes □ No (If not, please bring a copy)40c.If YES, circle type: Durable Power of Attorney Health Care Proxy Living Will40d.Who is responsible to carry out your wishes? _________________________ Relationship? _________________________40e.Circle Answer(s): Comfort Measures, DNR, Organ Donor, Resuscitate or NA Magnolia Family Medicine, Dr. Richard Gutsin Phone: 910-796-3212 3720 Shipyard Blvd, Wilmington NC 28403885825topFall Risk Checklist00Fall Risk ChecklistPatient Name________________________________________________ Date___________________ Fall Risk Factor IdentifiedFactor Present?NotesFalls History Any falls in past year? ? Yes ? NoWorries about falling or feels unsteady when standing or walking? ? Yes ? NoMedical ConditionsProblems with heart rate and/or rhythm ? Yes ? NoCognitive impairment ? Yes ? NoIncontinence ? Yes ? NoDepression ? Yes ? NoFoot problems ? Yes ? NoOther medical conditions (Specify) ? Yes ? No -107950189230Medications (Prescriptions, OTCs, supplements) STOP For Dr. Gutsin1515745501660PATIENTS STOP HERECNS or psychoactive medications ? Yes ? NoMedications that can cause sedation or confusion ? Yes ? NoMedications that can cause hypotension ? Yes ? No Gait, Strength & Balance Timed Up and Go (TUG) Test ≥12 seconds ? Yes ? No30-Second Chair Stand Test Below average score based on age and gender ? Yes ? No4-Stage Balance Test Full tandem stance <10 seconds ? Yes ? NoVisionAcuity <20/40 OR no eye exam in >1 year ? Yes ? NoPostural HypotensionA decrease in systolic BP >20 mm Hg or a diastolic BP of >10mm Hg or lightheadedness or dizziness from lying to standing?? Yes ? No Magnolia Family Medicine, Dr. Richard Gutsin Phone: 910-796-3212 3720 Shipyard Blvd, Wilmington NC 28403 Patient Health Questionnaire—PHQ-9 Name: _____________________________ Date of Birth: ______________ Today’s Date: __________ Fill in the boxes with pen or pencil to mark your answers.Over the last 2 weeks, how often have you been bothered by any of the following problems? Not at all 0 Several days 1 More than half the days 2 Nearly every day 3 1. Little interest or pleasure in doing things ? ? ? ? 2. Feeling down, depressed, or hopeless ? ? ? ? 3.Trouble falling/staying asleep, sleeping too much ? ? ? ? 4. Feeling tired or having little energy ? ? ? ? 5. Poor appetite or overeating ? ? ? ? 6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down ? ? ? ? 7. Trouble concentrating on things, such as reading the newspaper or watching television ? ? ? ? 8. Moving or speaking so slowly that other people could have noticed; or the opposite – being so fidgety or restless that you have been moving around a lot more than usual? ? ? ? 9. Thoughts that you would be better off dead or of hurting yourself in some way ? ? ? ? STAFF WILL CALCULATE SCORE Total Score _______ ____ _____ _____ _____ If you have been affected by any of the 9 problems listed above, please answer the following: How difficult have the problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult ? ? ? ? -3810028575FOR PHYSICIAN REPORTING ONLY: No Evidence of Depression No treatment needed Treatment plan in place already Discuss FurtherMagnolia Family Medicine, Dr. Richard Gutsin Phone: 910-796-3212 3720 Shipyard Blvd, Wilmington NC 28403 ................
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