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What do we treat?
Comprehensive and Preventative care
LGBTQ+
Vaccinations
Gender Affirmation care
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Meet the Team
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Before Making An Appointment
Make the Most of Your Visit
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Setting Up My Medical Locker
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About Colorectal Cancer Screening
Living With HIV - Indianapolis Urban League Support Team
Vaccination Information
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Prescription Request
Location and Hours
Send Us A Message
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Home
Services
Services Menu
Services
What do we treat?
Comprehensive and Preventative care
LGBTQ+
Vaccinations
Gender Affirmation care
Our Clinic
Our Clinic Menu
Our Clinic
About Us
Why Chatham Care?
Meet the Team
Office Informatioin
New Patients
Patient Resources
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
Insurance and Billing Menu
Insurance and Billing
Pay My Bill
Insurance Providers
My Medical Locker
Setting Up My Medical Locker
Resource Center
Resource Center Menu
Resource Center
General Information
Frequently Asked Questions (FAQ)
Prescription Savings Programs
About Colorectal Cancer Screening
Living With HIV - Indianapolis Urban League Support Team
Vaccination Information
Contact Us
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
Health Risk Assessment Form (HRA)
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?
Excellent
Very Good
Good
Fair
Poor
5.) In the last 2 weeks, how would you rate your overall level of pain compared to those in your age group?
No Pain
Very Mild Pain
Mild Pain
Moderate Pain
Severe Pain
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?
Do not have access
Within the last year
1-2 years ago
2-4 years ago
More than 5 years ago
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?
None - I do not drink
1-3 per week
4-6 per week
More than 7 per week
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?
150+ minutes
100-150 minutes
50-100 minutes
0-50 minutes
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
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