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Health Care Consumer Questionnaire
Patient DOB Date
Patient NameDateDOB Gender
Female
Male
SSNPatient AddressPhoneEmergency ContactPhoneHWCHWCPrimary InsurancePhoneSecondary InsurancePhone
Policy # Policy #
ListALL Health Care Providers fromwhom you are currentlyreceiving care
(or have seen within the past 12 months)
,ANDALL Health Care Providers fromwhom you are obtaining prescriptions.
Health Care ProviderPhoneHealth Care ProviderPhone
Haveyou completed Advance Health CareDirectives?
Yes
No
Please provide a copyas soon as possible
(Living Will or Durable Power of Attorney for Healthcar
e)If yes, please provide the name and contact information for your Health Care Power of AttorneyIf No, whom would you prefer as a surrogate decision maker should you need one?
Doyou have any religious or cultural beliefs thatmay affectyour healthcare?
If yes, explain
Describe the means bywhichyou prefer to learn new information
Verbal Instruction
Written Instruction
Handouts
Visual (Pictures, Videos, etc)
Languageyou prefer to converse inLevel of education completed
<6
th
grade
6
th
– 8
th
grade
9
th
grade
12
th
grade
1-4 years college
>4 yearscollege
If the person completing this form is not the patient, please writeyour full name, relationship to thepatient, and the specificreasons that the patient is unable to complete this form.
MB & RR 2008e-medtools.com
The information on this page wasreviewedwith the patient
HCC
Initials _____
HCP
Initials _____
1
Health Care Consumer Questionnaire
Patient DOB Date
Allergies
Please describe reactions
Shellfish
IV Contrast
Penicillins
Other,
specify
Please list medicationsyou are taking.
IncludeALL over the counter medications,herbs & vitamins.
Medication & Dose
Frequency
Medication & Dose
FrequencyHave you ever been exposed to knowncancer-causing agents or inhalation hazards?
Yes
No
Ifyes, please list the agents as specifically as possible, and state the duration of exposure as best as possible.
AgentDurationAgentDuration
Please list and describe your hobbiesHave you traveled in the past 12 months?
Yes
No
Ifyes, please list locations and time spent traveling.
Within the United States DurationOutside the United States Duration
Do you exercise?
Yes
No
If yes, please describe activities, frequency and duration of each activity
Activity & Duration Times/WeekActivity & Duration Times/Week
MB & RR 2008e-medtools.com
The information on this page wasreviewedwith the patient
HCC
Initials _____
HCP
Initials _____
2
Health Care Consumer Questionnaire
Patient DOB Date
SubstanceUse and Personal Risk History
Have you ever smoked tobacco as cigarettes, cigars or pipes?
Yes
No
#Packs #Years
Have you quit? If yes, when
Yes
NoHave you ever chewed tobacco?
Yes
No
#Pouches#Years
Have you quit? If yes, when
Yes
NoHave you considered quitting?
Yes
NoHave you tried quitting? If yes, for how long did you quit?
Yes
NoDo you drinkalcohol?
Yes
No
#Drinks
Day
Week
1 “drink” is equal to 12 oz.beer,1.5 oz. 80-proof liquor, or 5 oz. glass of wine
Have you ever lost consciousnessas a result of drinking alcohol?
Yes
NoHave you ever had a “drink” to prevent tremors, sweats, or irritability?
Yes
NoHave you ever been ticketed or arrestedfor a DUI?
Yes
NoHave you been involved in a motor vehicle accident in the past 12 months?
Yes
NoHave you ever used drugs for recreational purposes?
Yes
NoCheck all that apply
Amphetamines
Cocaine
Heroin
Inhalants
LSD
Marijuana
PCP
Other, specify
Method of drug delivery you used
Ingestion
Injection
InhalationHow much of each drug would you use?
List drugs below
AmountFrequency
Day
Week
Day
Week
Day
Week
Check all that apply
Have you ever been dependent on prescription drugs?
Yes
No
Narcotics
Benzodiazepines
Are you sexually active?
Yes
No
Specify If Other
If yes, do you use contraception of any kind?
Checkall that apply
Condoms
Diaphragm
Intrauterine Device IUD
Pills, Implants, PatchesHow many sexual partners haveyou had in the past 12 months?#Doyou feel safe in your relationship?
Yes
No
Haveyou ever been in a relationshipwhereyouwere threatened, hurt or afraid?
Yes
No
Doyouhave a safe place to go, and do you have the resources to leave, if you feel threatened?
Yes
NoHave you ever had sex with a person who is the same gender as yourself, bisexual,or anyone who performs sexual favors in exchange for money or drugs?
Yes
NoHave you ever been diagnosedwith a sexually transmitted disease
(such as syphilis,HIV, herpes, gonorrhea, chlamydia or genitalwarts)?
Yes
No
Do you have any tattoos or body piercings?
Yes
NoHave you ever received transfusions of blood or blood products?
Yes
NoDescribe your seatbelt use whether you are driving or are a passenger in a vehicle.
Allthe time
Most of the time
About h
alf the time
Rarely
Never Do you keep firearms in your residence?
Yes
No
If yes, are they kept in locked compartments, ordo theyhave safety locks on when not in use?
Yes
NoCan you perform your own hygiene, dressing, cooking and shopping needs?
Yes
No
MB & RR 2008e-medtools.com
The information on this page wasreviewedwith the patient
HCC
Initials _____
HCP
Initials _____
3
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