Form DHCS5103 "Client Health Questionnaire and Initial Screening Questions" - California

What Is Form DHCS5103?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2016;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHCS5103 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form DHCS5103 "Client Health Questionnaire and Initial Screening Questions" - California

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State of California — Health and Human Services Agency
Department of Health Care Services
Substance Use Disorders Compliance Division
Licensing and Certification Section, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
CLIENT HEALTH QUESTIONNAIRE AND INITIAL SCREENING QUESTIONS
HEALTH QUESTIONNAIRE INSTRUCTIONS
If Incidental Medical Services (IMS) are to be provided, the
Incidental Medical Services Certification
Form (DHCS
4026), and the
Health Care Practitioner Incidental Medical Services Acknowledgement
Form (DHCS
5256), must be completed, reviewed and signed by a Health Care Practitioner.
CLIENT HEALTH QUESTIONNAIRE
Name:
Date of Birth:
Date:
Physical
Yes No
1.
Have you ever had a heart attack or any problem associated with the heart? If yes, please
list when, what was the diagnosis and if you are currently taking medication:
2.
Are you currently experiencing chest pain(s)? If yes, please give details:
DHCS 5103 (06/16) Health Questionnaire and Initial Screening Form
Page 1
State of California — Health and Human Services Agency
Department of Health Care Services
Substance Use Disorders Compliance Division
Licensing and Certification Section, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
CLIENT HEALTH QUESTIONNAIRE AND INITIAL SCREENING QUESTIONS
HEALTH QUESTIONNAIRE INSTRUCTIONS
If Incidental Medical Services (IMS) are to be provided, the
Incidental Medical Services Certification
Form (DHCS
4026), and the
Health Care Practitioner Incidental Medical Services Acknowledgement
Form (DHCS
5256), must be completed, reviewed and signed by a Health Care Practitioner.
CLIENT HEALTH QUESTIONNAIRE
Name:
Date of Birth:
Date:
Physical
Yes No
1.
Have you ever had a heart attack or any problem associated with the heart? If yes, please
list when, what was the diagnosis and if you are currently taking medication:
2.
Are you currently experiencing chest pain(s)? If yes, please give details:
DHCS 5103 (06/16) Health Questionnaire and Initial Screening Form
Page 1
State of California — Health and Human Services Agency
Department of Health Care Services
Substance Use Disorders Compliance Division
Licensing and Certification Section, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
Yes No
3.
Do you have any serious health problems or illnesses (such as tuberculosis or active
pneumonia) that may be contagious to others around you? If yes, please give details:
4.
Have you ever tested positive for tuberculosis? If yes, when? Please give details:
5.
Have you ever been treated for HIV or Aids? If yes, when? Please give details:
6.
Have you ever been tested for sexually transmitted diseases? If yes, please give details and
list any medications you are taking:
7.
Have you had a head injury in the last six (6) months? Have you ever had a head injury that
resulted in a period of loss of consciousness? If yes, please give details:
8.
Have you ever been diagnosed with diabetes? If yes, please give details, including insulin,
oral medications, or special diet:
DHCS 5103 (06/16) Health Questionnaire and Initial Screening Form
Page 2
State of California — Health and Human Services Agency
Department of Health Care Services
Substance Use Disorders Compliance Division
Licensing and Certification Section, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
Yes No
9.
Do you have any open lesions/wounds? If yes, please explain and list any medications you
are taking:
10.
Have you ever had any form of seizures, delirium tremens or convulsions? If yes, date of last
seizure episode(s) and list any medications you are taking:
11.
Do you use a C-PAP machine or dependent upon oxygen? If yes, please explain:
12.
Have you ever had a stroke? If yes, please give details:
13.
Are you pregnant?
 3
st
nd
rd
a.
If yes, Which Trimester:
1
2
 Yes
 No
Are you receiving pre-natal care?
 Yes
 No
Any complications?
If yes, please explain:
14.
Do you have a history of any other illness that may require frequent medical attention? If yes,
please give details and list any medications you are taking:
DHCS 5103 (06/16) Health Questionnaire and Initial Screening Form
Page 3
State of California — Health and Human Services Agency
Department of Health Care Services
Substance Use Disorders Compliance Division
Licensing and Certification Section, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
Yes No
15.
Have you ever had blood clots in the legs or elsewhere that required medical attention?
If yes, please give details:
16.
Have you ever had high-blood pressure or hypertension? If yes, please give details:
17.
Do you have a history of cancer? If yes, please give details and list any medications you are
taking:
18.
Do you have any allergies to medications, foods, animals, chemicals, or any other substance?
If yes, please give details and list any medications you are taking:
19.
Have you ever had an ulcer, gallstones, internal bleeding, or any type of bowel or colon
inflammation? If yes, please give details:
20.
Have you ever been diagnosed with any type of hepatitis or other liver illness? If yes, please
give details and list any medications you are taking:
DHCS 5103 (06/16) Health Questionnaire and Initial Screening Form
Page 4
State of California — Health and Human Services Agency
Department of Health Care Services
Substance Use Disorders Compliance Division
Licensing and Certification Section, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
Yes No
21.
Have you ever been told you had problems with your thyroid gland, been treated for, or told
you need to be treated for, any other type of glandular disease? If yes, please give details:
22.
Do you currently have any lung diseases such as asthma, emphysema, or chronic bronchitis?
If yes, please give details:
23
Have you ever had kidney stones or kidney infections, or had problems, or been told you have
problems with your kidneys or bladder? If yes, please give details:
24.
Do you have any of the following; arthritis, back problems, bone injuries, muscle injuries, or
joint injuries? If yes, please give details, including any ongoing pain or disabilities:
25.
Do you take over the counter pain medications such as aspirin, Tylenol, or Ibuprofen? If yes,
list the medication(s) and how often you take it:
26.
Do you take over the counter digestive medications such as Tums or Maalox? If yes, list the
medication(s) and how often you take it:
DHCS 5103 (06/16) Health Questionnaire and Initial Screening Form
Page 5