Fillable CLIENT HEALTH QUESTIONNAIRE AND INITIAL SCREENING QUESTIONS (Department of Health Care Services)

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CLIENT HEALTH QUESTIONNAIRE AND INITIAL SCREENING QUESTIONS (Department of Health Care Services)

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State of California — Health and Human Services Agency Department of Health Care Services
Substance Use Disorders Compliance Division
Licensing and Certification Section, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
CLIENT HEALTH QUESTIONNAIRE AND INITIAL SCREENING QUESTIONS
HEALTH QUESTIONNAIRE INSTRUCTIONS
If Incidental Medical Services (IMS) are to be provided, the
Incidental Medical Services Certification
Form (DHCS 4026)
, and the
Health Care Practitioner Incidental Medical Services Acknowledgement
Form (DHCS 5256), must be completed, reviewed and signed by a Health Care Practitioner.
CLIENT HEALTH QUESTIONNAIRE
Name: Date of Birth:
Date:
Physical
1.
Yes No
Have you ever had a heart attack or any problem associated with the heart? If yes, please
list when, what was the diagnosis and if you are currently taking medication:
2.
Are you currently experiencing chest pain(s)? If yes, please give details:
DHCS 5103 (06/16) Health Questionnaire and Initial Screening Form Page 1
State of California — Health and Human Services Agency Department of Health Care Services
Substance Use Disorders Compliance Division
Licensing and Certification Section, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
3.
Yes
No
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:
4.
Have you ever tested positive for tuberculosis? If yes, when? Please give details:
5.
Have you ever been treated for HIV or Aids? If yes, when? Please give details:
6.
Have you ever been tested for sexually transmitted diseases? If yes, please give details and
list any medications you are taking:
7.
Have you had a head injury in the last six (6) months? Have you ever had a head injury that
resulted in a period of loss of consciousness? If yes, please give details:
8.
Have you ever been diagnosed with diabetes? If yes, please give details, including insulin,
oral medications, or special diet:
DHCS 5103 (06/16) Health Questionnaire and Initial Screening Form Page 2
State of California — Health and Human Services Agency Department of Health Care Services
Substance Use Disorders Compliance Division
Licensing and Certification Section, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
9.
Yes No
10.
11.
12.
13.
Are you pregnant?
a. If yes, Whi
ch Trimester: 1
st
2
nd
3
rd
Are you receiving pre-natal care?
Yes
No
Any
complications?
Yes
No If yes, please explain:
14.
DHCS 5103 (06/16) Health Questionnaire and Initial Screening Form Page 3
State of California — Health and Human Services Agency Department of Health Care Services
Substance Use Disorders Compliance Division
Licensing and Certification Section, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
15.
Yes No
Have you ever had blood clots in the legs or elsewhere that required medical attention?
If yes, please give details:
16.
Have you ever had high-blood pressure or hypertension? If yes, please give details:
17.
Do you have a history of cancer? If yes, please give details and list any medications you are
taking:
18.
Do you have any allergies to medications, foods, animals, chemicals, or any other substance?
If yes, please give details and list any medications you are taking:
19.
Have you ever had an ulcer, gallstones, internal bleeding, or any type of bowel or colon
inflammation? If yes, please give
details:
20.
Have you ever been diagnosed with any type of hepatitis or other liver illness? If yes, please
give details and list any medications you are taking:
DHCS 5103 (06/16) Health Questionnaire and Initial Screening Form Page 4
State of California — Health and Human Services Agency Department of Health Care Services
Substance Use Disorders Compliance Division
Licensing and Certification Section, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
21.
Yes
No
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:
22.
Do you currently have any lung diseases such as asthma, emphysema, or chronic bronchitis?
If yes, please give details:
23
.
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:
24.
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:
25.
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:
26.
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:
DHCS 5103 (06/16) Health Questionnaire and Initial Screening Form Page 5
State of California — Health and Human Services Agency Department of Health Care Services
Substance Use Disorders Compliance Division
Licensing and Certification Section, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
27.
Yes
No
Do you wear or need to wear glasses, contact lenses, or hearing aids? If yes, please give
details:
28.
When was your last dental exam?
Date:
29.
Are you in need of dental care? If yes, please give details:
30.
Do y
ou wea
r o
r ne
e
d t
o wear dentures or other dental appliances that may require dental care?
If yes, please give details:
31. Please describe any surgeries or hospitalizations due to illness or injury that you have had in the past.
32. When was the last time you saw a physician and/or psychiatrist? What was the purpose of the visit?
Please give details:
DHCS 5103 (06/16) Health Questionnaire and Initial Screening Form Page 6
State of California — Health and Human Services Agency Department of Health Care Services
Substance Use Disorders Compliance Division
Licensing and Certification Section, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
33.
In the past seven days what types of drugs, including alcohol, have you used?
Type of Drug Route of Administration
34. In the past year what types of drugs, including alcohol, have you used?
Type of Drug Route of Administration
35. Do you take any prescription medications including psychiatric medications?
Type of Drug Route of Administration
Mental/Emotional
36.
Yes No
Are you cur
rently feeling down, depressed, anxious or hopeless? If yes, describe:
37.
Are you currently receiving treatment services for anemotional/psychiatric diagnosis? If yes,
for what are you being treated?
DHCS 5103 (06/16) Health Questionnaire and Initial Screening Form Page 7
State of California — Health and Human Services Agency Department of Health Care Services
Substance Use Disorders Compliance Division
Licensing and Certification Section, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
38.
Yes
No
Over the last 2 weeks, have you felt nervous, anxious, or on edge? Did you feel like you were
unable to stop or control your worrying? If yes, describe:
39.
Over the last 2 weeks, have you had thoughts of suicide or thought that you would be better
off dead? If yes, describe:
40.
Have you attempted suicide in the past two (2) years? If yes, give dates:
41.
Have you ever harmed yourself/others or thought about harming yourself/others? If yes,
describe:
42.
Are you currently feeling that you’re hearing voices or seeing things? If yes, describe:
43.
Have you ever been in a relationship where your partner has pushed or slapped you?
If yes, describe:
DHCS 5103 (06/16) Health Questionnaire and Initial Screening Form Page 8
State of California — Health and Human Services Agency Department of Health Care Services
Substance Use Disorders Compliance Division
Licensing and Certification Section, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
Previous Drug and/or Alcohol Treatment Services
44.
Have you received alcoholism or drug abuse recovery treatment services in the past? If yes, please
give details:
Type of Previous
Recovery Treatment
(Outpatient, Residential,
Detoxification)
Name of Previous
Treatment Facility
Dates of Previous
Treatment
Treatment
Completed
(Yes or No)
45.
Have you ever been treated for withdrawal symptoms? If so, please state the dates you were treated
and list any medications that were prescribed:
I declare that the above information is true and correct to the best of my knowledge:
Client Signature: Today’s Date:
Reviewing Facility/Program Staff Name:
Reviewing Facility/Program Staff Signature: Date:
DHCS 5103 (06/16) Health Questionnaire and Initial Screening Form Page 9
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State of California — Health and Human Services Agency Department of Health Care Services
Substance Use Disorders Compliance Division
Licensing and Certification Section, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
DHCS 5103 (06/16) Health Questionnaire and Initial Screening Form Page 10
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CLIENT HEALTH QUESTIONNAIRE AND INITIAL SCREENING QUESTIONS (Department of Health Care Services)

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Completed 21 October 2021

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