| What is your date of birth? | |
| What is your Email address? | |
| What is your mailing address? | |
| What is your telephone number? | |
| Where is the patient now? | |
| How old is the patient? | |
| What is the gender of the patient? | |
| What are the sources of medical history? | |
| What best describes the patient?: | |
| In general, how is your physical and mental health? | |
| Do you have any appointments scheduled with doctors or other specialists? |
Yes No |
| Have you been in the hospital in the last month? |
Yes No |
| Do you have health problems that you need help with right away? |
Yes No |
| Do you need extra help to access services, such as a wheelchair ramp, a computer screen reader or large print materials? |
Yes No |
|
Screening for survival needs Do you have enough of these resources from the state? Food Clothing Housing Health care Transportation Security Education Consumer goods Communication Do you need any of these resources to be enhanced? | |
|
What are the issues? | |
|
These are basic questions. There are many more. Once the above listed relevant questions about comprehensive patient assessment are answered and received, you will get another questions list relevant to age, gender, location, problems, or issues, if any. This will be followed by specific recommendations. | |