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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)

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