Horizon

All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers

ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL.

If yes, are you on a physician prescribed medical diet?

# of meals you eat in an average day?

Are you concerned about the amount you drink?

Have you ever experienced blackouts?

Are you prone to "binge" drinking?

Do you currently use recreational or street drugs?

Have you ever given yourself street drugs with a needle?

If yes, are you trying for a pregnancy?

If not trying for a pregnancy list contraceptive or barrier method used:

Illness related to the Human Immunodeficiency Virus (HIV), such as AIDS, has become a major public health problem. Risk factors for this illness include intravenous drug use and unprotected sexual intercourse. Would Yes you like to speak with your provider about your risk of this illness?

Do you have vision or hearing loss?

Do you have an Advance Directive or Living Will?

Would you like information on the preparation of these?

Physical and/or mental abuse have also become major public health issues in this country. This often takes the form of verbally threatening behavior or actual physical or sexual abuse. Would you like to discussthis issue with your provider?

Is stress a major problem for you?

Do you have problems with eating or your appetite?

Have you ever attempted suicide?

Have you ever seriously thought about hurting yourself?

Have you ever been to a counselor?

Have you had a D&C, hysterectomy, or Cesarean?

Any urinary tract, bladder, or kidney infections within the last year?

Any problems with control of urination?

Any hot flashes or sweating at night?

Do you have menstrual tension, pain, bloating, irritability, or other symptoms at or around time of period?

Experienced any recent breast tenderness, lumps, or nipple discharge?

Date of last pap and rectal exam?

Do you feel burning discharge from penis?

Has the force of your urination decreased?

Have you had any kidney, bladder, or prostate infections within the last 12 months?

Do you have any problems emptying your bladder completely?

Any difficulty with erection or ejaculation?

Any testicle pain or swelling?

Date of last prostate and rectal exam?

Check if you have, or have had, any symptoms in the following areas to a significant degree and briefly explain.