Initial Screening Questionnaire

Drug Screening Questionnaire (DAST) - SBIRT Oregon

Drug Screening Questionnaire (DAST) Using drugs can affect your health and some medications you may take. Please help us provide you with the best ... and should occur in the same session as the initial screening. Repeated sessions are more effective than a …

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FAQ for Employer's Providing Tuberculosis Screening

FAQs for Employers Providing Tuberculosis Screening . ... After the initial chest x-ray, a sign and symptom questionnaire (an example can be found here) [8] should be administered annually. If symptomatic, the employee should complete a chest x …

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Screening Questionnaire COVID-19 (Coronavirus)

Screening Questionnaire – COVID-19 (Coronavirus) Questions asked at initial screening: Name:_____ Date:_____ Please circle the appropriate responses. 1. Do you currently have symptoms of a respiratory infection? a. NO b. YES. – (If so, please indicate your symptoms) Fever Shortness of breath Cough Sore throat Loss of Smell Loss of Appetite ...

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Ages & Stages Questionnaires 2 Month Questionnaire

2 Month Questionnaire page 4 of 5 E101020400 YES SOMETIMES NOT YET PERSONAL-SOCIAL TOTAL OVERALL Parents and providers may use the space below for additional comments. 1. Did your baby pass the newborn hearing screening test? If no, explain: 2. Does your baby move both hands and both legs equally well? If no, explain: 3.

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Ages & Stages Questionnaires 9 Month Questionnaire

Month Questionnaire 9 months 0 days through 9 months 30 days Please provide the following information. Use black or blue ink only and print legibly when completing this form. 9 Baby’s first name: Baby’s last name: Baby’s date of birth: First name: Last name: Middle initial: City: Home telephone number: State/ Province: ZIP/ Postal code ...

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Ages & Stages Questionnaires: Social-Emotional

First name: Middle initial: Last name: 2 Month Questionnaire 1 month 0 days through 2 months 30 days Date asQ:se- 2 completed: _____ Baby’s information Baby’s fi rst name: Baby’s middle initial: Baby’s last name: Baby’s date of birth: If baby was born 3 or more weeks premature,

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Ages & Stages Questionnaires 30 Month Questionnaire

30 Month Questionnaire 28 months 16 days through 31 months 15 days Important Points to Remember: Try each activity with your baby before marking a response. Make completing this questionnaire a game that is fun for you and your child. Make sure your child is rested and fed. Please return this questionnaire by _____. Notes:

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The AHC Health-Related Social Needs Screening Tool

process for each screening question in the AHC HRSN Screening Tool if the questions are used outside of CMS and the AHC Model. Center for Medicare adicaidnd Me Innovation 2 . Accountable Health Communities Health-Related Social Needs Screening Tool Citation and Notification Information

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Strengths and Difficulties Questionnaire (SDQ)

Strengths and Difficulties Questionnaire Not True Somewhat True Certainly True 1. Considerate of other people‟s feelings 2. Restless, overactive, cannot stay still for long 3. Often complains of headaches, stomach-aches or sickness 4.

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CHAPTER 7. RECERTIFICATION, UNIT TRANSFERS, AND …

HUD Multifamily Occupancy Handbook 7-2 8/13 Chapter 7: Recertification, Unit Transfers, and Gross Rent Changes 4350.3 REV-1 7-2 Key Terms A. There are a number of technical terms used in this chapter that have very