Source: State of California Office of Clinical Preventive Medicine
WASHINGTON — Physicians have limited time to devote to preventive care, but a short questionnaire mailed to patients prior to their visit or administered in the waiting room could change this.
A 20-item questionnaire to promote brief prevention counseling during patient visits was presented at the annual meeting of the American College of Preventive Medicine by Larry Dickey, M.D., of the California Department of Health Services, Sacramento.
Dr. Dickey shared the “Staying Healthy” Assessment questionnaires developed by his department that are now standard for all Medicaid patients in California. Pilot studies of the questionnaires show that they were well received by patients, and their use triggered doctors to provide brief preventive medicine counseling, but formal evaluations are pending.
The sample below is for Medicaid patients aged 18 years and older. To view the questionnaires for all age groups in PDF form, visit www.dhs.ca.gov/ps/ocpm/html/staying%20healthy.htm
Answers for the questionnaire include choices of “yes,” “no,” or “skip.”
1. Do you receive health care from anyone besides a medical doctor, such as an acupuncturist, herbalist, curandero, or other healer?
2. Do you see the dentist at least once a year?
3. Do you drink milk or eat yogurt or cheese at least three times each day?
4. Do you eat at least five servings of fruits or vegetables each day?
5. Do you try to limit the amount of fried or fast foods that you eat?
6. Do you exercise or do moderate physical activity such as walking or gardening 5 days a week?
7. Do you think you need to lose or gain weight?
8. Do you often feel sad, down, or hopeless?
9. Do you have friends or family members who smoke in your house?
10. Do you often spend time outdoors without sunscreen or other protection such as a hat or shirt?
11. Do you smoke cigarettes or cigars or use any other kinds of tobacco?
12. Do you use any drugs or medicines to go to sleep, relax, calm down, feel better, or lose weight?
13. Do you often have more than two drinks containing alcohol in 1 day?
14. Do you think you or your partner could be pregnant?
15. Do you think you or your partner could have a sexually transmitted disease?
16. Have you or your partner(s) had sex without using birth control in the last year?
17. Have you or your partner(s) had sex with other people in the past year?
18. Have you or your partner(s) had sex without a condom in the past year?
19. Have you ever been forced or pressured to have sex?
20. Have you ever been hit, slapped, kicked, or physically hurt by someone?
Do you have other questions/concerns about your health? (Please identify.)