Health Screening Questionnaire Santa Clara County Behavioral Health Services / Substance Use Treatment Services

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Client: Gender: F M Binary Age: ProFiler# Date:

1. Primary drug used: Amount used: How used: Per days / week: Age of first use: Date of last use:

2. Other drug(s) used: a. b

c

Tobacco / Nicotine How used / amount:How many days / week:Date of last use: Alcohol Use

3. Do you drink alcohol? No Yes 4. Have you ever felt you should cut down on your drinking? No Yes 5. Have people annoyed you by criticizing your drinking? No Yes 6. Have you ever felt bad or guilty about drinking? No Yes 7. Have you ever had a drink first thing in the morning to calm your nerves, or treat a hangover? No Yes 8. What do you drink? 9. How often? days/w

10. On a day you drink, how many do you have? 11. When was your last drink?12. Do you get severe side effects if you stop drinking? No Yes 13. Have you ever had hallucinations or seizures when you stopped drinking? No Yes 14. Have you ever been hospitalized for alcohol withdrawal? No Yes 15. Do you need medications to help you stop using alcohol? No Yes

General Medical Questions:16. Do you have a doctor? No Yes MD Name: MD Phone # Fax #

17. When was your last physical exam?18. Do you require medical care at this time? No Yes 19. Would you like information on Hepatitis C / HIV / or family planning? No Yes 20. Do you have a serious physical illness or mental health illness? No Yes If yes, please list

21. Do you take medications? No Yes 22. Women: Last menstrual?

If yes, please list: Are you pregnant: No Y es If Yes, when is baby due?

Tuberculosis Screen: 23. When was your last TB test? Result was: Pos Neg Pending

24. Do you have a new cough or increased cough lasting more than 3 weeks? No Yes 25. Are you losing weight (without trying to diet) over the last year? No Yes 26. Do you have unexplained fever or drenching night sweats? No Yes 27. Have you ever taken any medications for TB? No Yes 28. Have you ever taken a Chest X-Ray for TB? No Yes

Have you recently (in the past 30 days) experienced any of the following: Potential life threatening conditions: Serious health conditions: Concern for poor health conditions:

Stroke No Yes Vomiting blood No Yes Jaundice or diabetes No Yes Chest pain/Irregular heart beat No ☐ Yes

High blood pressure or hypertension

No Yes Yellow or black stools or Internal bleeding No Yes

Contagious disease, chronic, cough eg. Pneumonia No Yes

History of cancer No Yes Indigestion, Nausea, vomiting or ulcers No Yes

Head injury w/loss of consciousness No Yes

Severe heartburn or Abdominal pain No Yes Swollen glands,

fevers No Yes

Seizures, delirium tremens or convulsions No Yes

Medical attention for blood clots No Yes Painful urination or

discharge or diarrhea No Yes

Shortness of breath No ☐ Yes Suicidal thoughts No Yes Kidney infections or stones

No Yes

Client Signature: ________________________ Date: __________ Counselor Printed name:

Signature, License/Credential & #:______________________________

Health Screening Questionnaire Santa Clara County Behavioral Health Services / Substance Use Treatment Services

11.02.2017 sl

MD Printed Name: License: _______

MD Signature: ______________________________________ Date: _______ SUTS Counseling Staff: I have read the physician feedback, will communicate it to the client, and

incorporate physician feedback into the Treatment Plan as per above.

Counselor Printed Name, credential and license #:

Counselor Signature: ______________________________________________ Date: _______

MEDICAL ELIGIBILITY

______

______

______

Patient DOES NOT meet medical eligibility for Substance Use Disorder(s) treatment services based on the information provided in this HSQ. If the following information is available, resubmit HSQ with below additional info for further consideration of medical necessity: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

MEDICAL ELIGIBILITY AND PHYSICAL EXAMINATION

Patient meets medical eligibility for Substance Use Disorder(s) treatment services based on the information provided in this HSQ.

Patient MAY NOT BEGIN substance use disorder treatment until completion of physical exam and medical clearance letter. This is due to medical problems precluding participation without medical clearance.

______ Patient MAY BEGIN substance use disorder treatment, as per below:

� Patient has not had a physical exam within the last 12 months and must be referred to obtain a physical exam. Obtaining physical exam must be documented as a Dimension 2 treatment plan item, and efforts to complete must be consistently noted in progress notes.

� Patient has had a physical exam within the last 12 months, and results are in the chart.

� Offer patient referral to MAT program for potential medication assisted treatment options.

� Based on review of this HSQ, add the following medical issue to Treatment Plan

1.

ADDITIONAL ITEMS TB testing is recommended. Refer to TB nurses for follow-up. Offer educational materials on Hepatitis C, HIV, and Family Planning Services

(Dimension 2 Biomedical Conditions/ Complications)

2.