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1500 Village Run Rd, #308, Wexford, PA 15090

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Patient Questionnaire one

Patient First Name

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Patient Last Name

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Date of Visit:

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DOB:

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Email

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Social History

Social History

Do you eat a healthy balanced diet with minimal salt and bad fats?

Please select an option.

For Example: Balanced Diet = Combination of fruits, vegetables, grains, low-fat dairy each day. Minimal Salts = Less than one teaspoon per day. Bad Fats = Fried Food, Fast Food, packaged foods from a box.

Have you had any unintentional weight loss in the past 6 months?

Please select an option.

If so, what is the amount of your recent weight loss: lbs

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Malnutrition

Malnutrition

The responses to the following questions should consider the patient response and provider assessment:

Inadequate calorie intake?

Please select an option.

Loss of muscle mass?

Please select an option.

Loss of fat beneath skin (subcutaneous fat)?

Please select an option.

Localized or generalized fluid accumulation?

Please select an option.

Diminished functional status?

Please select an option.

Smoking History

Smoking History

What is your history of smoking cigarettes?

Please select an option.

If Current Smoker or Former Smoker, how many pack years? (packs per day x number of years smoked)

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If yes, you used to smoke, when did you stop smoking cigarettes?

Please select an option.

Drug History

Drug History

No History of Illegal Drug Use (Prescription or Street Drugs)

Illegal Drug Use (Prescription and/or Street Drugs) (Current or in Remission)

If Illegal Drug Use, please select drug(s) below:

Cocaine

Other Stimulant

Opioid

Hallucinogens

Cannabis

Inhalants

Sedative, Hypnotic or Anxiolytic

Other Psychoactive Substances

If any drug(s) selected, please select one of the following:

Please select an option.

If any drug(s) selected, please select if applicable:

Complications (Mood, Psychotic, Sleep, Anxiety, Sexual or Unspecified Disorders)

Alcohol History

Alcohol History

No Current Use of Alcohol

Social Alcohol Use

Complications (Mood, Psychotic, Sleep, Anxiety, Sexual or Unspecified Disorders)

Please select an option.

Alcohol Abuse

Complications (Mood, Psychotic, Sleep, Anxiety, Sexual or Unspecified Disorders)

Please select an option.

Alcohol Dependency (Current)

Complications (Mood, Psychotic, Sleep, Anxiety, Sexual or Unspecified Disorders)

Please select an option.

Alcohol Dependency (In Remission)

Complications (Mood, Psychotic, Sleep, Anxiety, Sexual or Unspecified Disorders)

Please select an option.

Select if applicable in addition to use, abuse or dependency:

Women:

Please select an option.

Do you drink (7 or more alcoholic drinks per week or 3 or more per episode of drinking?)

Men:

Please select an option.

Do you drink 14 or more alcoholic drinks per week or 4 or more per episode?

Self-Assessment

Self-Assessment

Considering your age, how would you describe your overall health?

Please select an option.

How much difficulty, if any, do you have walking a ¼ mile which is about 2 or 3 blocks?

Please select an option.

In the past 7 days, how many days did you exercise?

Please select an option.

Have you been to the dentist in last 12 months?

Please select an option.

Depression Assessment

Depression Assessment

Over the past 2 weeks, have you felt down, depressed, or hopeless?

Please select an option.

Over the past 2 weeks, have you felt little interest or pleasure in doing things?

Please select an option.

Are you taking any depression medications?

Please select an option.

Fall Risk & Home Safety

Fall Risk & Home Safety

Do you always fasten your seat belt when you are in a car?

Please select an option.

Do you have any problems with your hearing?

Please select an option.

Do you have a problem with balance?

Please select an option.

Do you have a problem walking?

Please select an option.

A fall is when your body goes to the ground without being pushed. Have you fallen in the past 12 months?

Please select an option.

If Yes to Fall:

Were you injured from the fall?

Please select an option.

Have you had more than one fall?

Please select an option.

Activities of Daily Living Scale

Activities of Daily Living Scale

In the past 7 days, did you need help to perform everyday activities such as eating, getting dressed, grooming, bathing, walking, getting in or out of bed or a chair, or using the toilet?

Please select an option.

If yes, check all that apply:

Eating

Getting dressed

Bathing

Walking

Getting in and out of bed/chair

Using the toilet

In past 7 days, did you need help from others to take care of things such as laundry and housekeeping, banking, shopping, using the telephone, food preparation, transportation or taking medications?

Please select an option.

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