HEALTH AND WELLNESS SCREENING - True North Recovery

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)*

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?*

Increasing
Decreasing
Same

Are you currently receiving treatment for your pain?*

Yes
No

May we request those records to coordinate your care?*

Yes
No

Do you have a primary care physician?*

Yes
No

Have you received a physical in the past twelve months?*

Yes
No

If yes, please describe the findings of the physical

May we request those records to coordinate your care?*

Yes
No

Do you have a dentist?*

Yes
No

Have you received a dental care in the past twelve months?*

Yes
No

May we request those records to coordinate your care?*

Yes
No

Do you have any food allergies?*

Yes
No

If yes, please describe

Do you have any medication allergies?*

Yes
No

If yes, please describe

Do you have any animal allergies?*

Yes
No

If yes, please describe

Do you have any environmental allergies?*

Yes
No

If yes, please describe

Do you have any cultural preferences as it relates to your treatment?*

Yes
No

If yes, please describe*

Have you experienced any weight loss or gain of ten of more pounds in the past 90 days?*

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?*

Yes
No

If yes, please describe

Can you identify any unhealthy patterns or behaviors as it relates to your eating/ drinking habits?*

Yes
No

If yes, please describe

Have you ever been diagnosed with an eating disorder?*

Yes
No

If yes, please describe

Select The Most Accurate Option

Physical Abuse*

In immediate danger
Currently experiencing
Experienced in the last 90 days
Have experienced in my lifetime

Emotional Abuse*

In immediate danger
Currently experiencing
Experienced in the last 90 days
Have experienced in my lifetime

Sexual Abuse*

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*

In immediate danger
Currently experiencing
Experienced in the last 90 days
Have experienced in my lifetime

Domestic Violence*

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)