Healthcare Monthly Questionnaire

HEALTHCARE MONTHLY QUESTIONNAIRE

Questionnaire for Month: Year: Facility/Clinic Name:

Patient Information

Date of Birth: Gender: Male Female Other

Insurance Information

Current Health Status

Have you been hospitalized or had an emergency room visit since last month? Yes No

Any new diagnoses, new or changed treatments, or recent surgeries? Yes No

Medications and Allergies

Have there been any medication changes (new, stopped, dose change)? Yes No

Symptoms and Functional Status

Please check any new or worsening symptoms experienced this month:

Fever or chills Persistent cough Shortness of breath Chest pain Dizziness or fainting

Increased pain Mobility decline or new need for assistive device Depression / anxiety worsening New skin breakdown or wounds

Current pain level (0 = none, 10 = worst):

Any falls or near-falls this month? Yes No

Has the patient's need for assistance with activities of daily living increased this month? Yes No

Mental Health and Substance Use

New or worsening mental health concerns (e.g., increased depression, anxiety, suicidal thoughts)? Yes No

Substance use concerns or changes (alcohol, tobacco, recreational drugs)? Yes No

Advance Directives & Care Preferences

Does the patient have an advance directive, living will, or durable power of attorney for healthcare? Yes No

Authorization, Privacy, and Certification

I authorize the release and exchange of the health information provided in this questionnaire to members of my clinical care team, related ancillary providers, and my designated caregivers for continuity of care, care coordination, and treatment planning. This authorization includes information about diagnoses, medications, treatments, and functional status disclosed herein.

I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it. This authorization will expire on:

I acknowledge that the information I provide is complete and accurate to the best of my knowledge. I understand that intentionally providing false information may have legal or clinical consequences and may affect the care plan. I consent to the release of this information for treatment, payment, and health care operations as permitted by law.

Consent to share with family/caregiver: Yes No

Certification: By signing below I certify that I am the patient or the patient's authorized representative. I affirm that I have read and understand the statements above and that the information provided is truthful and complete.

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