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TNR RECOVERY STORIES
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CAREERS
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HEALTH AND WELLNESS SCREENING
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" indicates required fields
Health and Wellness Screening
Please rate your current level of PHYSICAL pain on a scale from zero to ten, with zero representing no pain and ten representing extreme pain. (Please Select One)
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1
2
3
4
5
6
7
8
9
10
If you are currently in pain, please describe the pain, and how long you have been experiencing the symptoms:
Is your pain increasing, decreasing, or remaining the same?
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Increasing
Decreasing
Same
Are you currently receiving treatment for your pain?
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Yes
No
May we request those records to coordinate your care?
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Yes
No
Do you have a primary care physician?
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Yes
No
Have you received a physical in the past twelve months?
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Yes
No
If yes, please describe the findings of the physical
May we request those records to coordinate your care?
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Yes
No
Do you have a dentist?
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Yes
No
Have you received a dental care in the past twelve months?
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Yes
No
May we request those records to coordinate your care?
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Yes
No
Do you have any food allergies?
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Yes
No
If yes, please describe
Do you have any medication allergies?
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Yes
No
If yes, please describe
Do you have any animal allergies?
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Yes
No
If yes, please describe
Do you have any environmental allergies?
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Yes
No
If yes, please describe
Do you have any cultural preferences as it relates to your treatment?
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Yes
No
If yes, please describe
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Have you experienced any weight loss or gain of ten of more pounds in the past 90 days?
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Yes
No
If yes, please describe
Have you had an increase or decrease if your food/drink intake or appetite in the past 90 days?
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Yes
No
If yes, please describe
Can you identify any unhealthy patterns or behaviors as it relates to your eating/ drinking habits?
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Yes
No
If yes, please describe
Have you ever been diagnosed with an eating disorder?
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Yes
No
If yes, please describe
Select The Most Accurate Option
Physical Abuse
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In immediate danger
Currently experiencing
Experienced in the last 90 days
Have experienced in my lifetime
Emotional Abuse
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In immediate danger
Currently experiencing
Experienced in the last 90 days
Have experienced in my lifetime
Sexual Abuse
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In immediate danger
Currently experiencing
Experienced in the last 90 days
Have experienced in my lifetime
Trauma
In immediate danger
Currently experiencing
Experienced in the last 90 days
Have experienced in my lifetime
Neglect
In immediate danger
Currently experiencing
Experienced in the last 90 days
Have experienced in my lifetime
Exploitation
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In immediate danger
Currently experiencing
Experienced in the last 90 days
Have experienced in my lifetime
Domestic Violence
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In immediate danger
Currently experiencing
Experienced in the last 90 days
Have experienced in my lifetime
In the following table please indicate if you have experienced any of the following: Abuse, Trauma, Neglect, or Exploitation and Domestic Violence. Please indicate by placing an “X’ in all the boxes that apply. By indicating you have had an experience in any of these areas, we will explore those further in your assessment session. *** if you indicate you are in immediate danger TNR staff will immediately work with you to address the dangers, develop a crisis plan and in some case intervene through mandatory reporting practices.
(if you have questions regarding this section, please check in with TNR staff)
Are You Human? Answer This: 7+2=?
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