Home
New Patients
- General Information
- Frequently Asked Questions (FAQ)

Home
- Services Menu
- Services
- What do we treat?
- Comprehensive and Preventative care
- LGBTQ+
- Vaccinations
- Gender Affirmation care
- Our Clinic Menu
- Our Clinic
- About Us
- Why Chatham Care?
- Meet the Team
- Office Informatioin
New Patients
- Patient Resources Menu
- Patient Resources
- Before Making An Appointment
- Make the Most of Your Visit
- Patient Privacy
- Patient Forms
- Telehealth
- Lifestyle medicine
- Insurance and Billing Menu
- Insurance and Billing
- Pay My Bill
- Insurance Providers
- My Medical Locker
- Setting Up My Medical Locker
- Resource Center Menu
- Resource Center
- General Information
- Frequently Asked Questions (FAQ)
- Contact Us Menu
- Contact Us
- Request an Appointment
- Prescription Request
- Location and Hours
- Send Us A Message

Health Risk Assessment Page

This survey will take 5 - 10 minutes. Please complete before your appointment, and give the finished survey to your Care Provider.

Name and DOB (First , Last)(DD/MM/YYYY)

Email *

Type of Form

General Information
1.) In the last 12 months, have you seen any other healthcare provider outside of our clinic?
Yes
No

2.) Have you been hospitalized since we last saw you?
Yes
No

3.) Do you have trouble affording medication?
Yes
No

Self-Assesment
4.) In the last 12 months, how would you rate your overall health compared to those in your age group? 5.) In the last 2 weeks, how would you rate your overall level of pain compared to those in your age group? 6.) How would you describe your dental health?
Poor
Good

7.) Do you have concerns about your vision?
Yes
No

8.) When was the last time you had a routine eye exam? 9.) In the past year, have you had any significant negative life changes (i.e. death of a relative or close friend, divorce, illness or injury, job loss, financial burdens, etc.)?
Yes
No

10.) Do you generally feel rested when you wake up?
Yes
No

Tobacco Use
11.) Do you smoke or use any tobacco related products?
Yes
No

Alcohol/Illicit Drug Use
12.) In a typical week, how many drinks containing alcohol do you typically consume? 13.) In the last 12 months, have you used drugs other than those required for medical reasons?
Yes
No

14.) Please check any activities you are no longer able to do on your own?
Dressing
Feeding
Toileting
Grooming
Bathing
Instrumental Activities of Daily Living
15.) Please check any activities you are no longer able to do on your own?
Shopping
Food Preparation
Using the telephone
Housekeeping
Using transportation
Taking medication
Managing

Physical Activity
16.) On average, How many minutes do you exercise a week? Home and Work Risks
17.) Do you feel safe at work and home?
Yes
No

18.) Have you ever been a victim of threats, physical violence or forced sexual contact?
Yes
No

Sexual Activity
19.) Are you sexually active?
Yes
No

20.)In the past 12 months, have you had unprotected sex with a new sex partner?
Yes
No

21.)In the past 12 months, have you been treated for any sexually transmitted disease (STD)?
Yes
No

Dietary Habits
22.) Do you believe you have enough information to make healthy eating and dietary choices?
Yes
No

Location and Hours

907 N East St
Indianapolis, IN 46202

Questions? Call us
Phone: (317) 644-3461
Fax: (317) 602-2654

Email: Reception@ChathamCare.com

Hours: Mon - Fri (8 am to 12 pm), (1 pm - 5 pm)

General Information

Search
About Us
Why Chatham Care
Careers
Office Information

Patient Link

Make an Appointment
Telehealth
My Medical Locker
Setting Up My Medical Locker
Accepted Insurance Providers
Pay My Bill
Assessment

Legal Information

Legal Notices
Disclaimer
Non-discrimination Notice
Patient Privacy
Patient Rights & Responsibilities
Social Media Site User Agreement

Facebook

Use left/right arrows to navigate the slideshow or swipe left/right if using a mobile device

Choosing a selection results in a full page refresh.
Press the space key then arrow keys to make a selection.