County of Sacramento
Department of Health and Human Services
Division of Behavioral Health Services
Policy and Procedure
Policy Issuer
(Unit/Program)
Policy Number
Effective Date
QM
QM-10-25
04-20-1997
Title:
Health Questionnaire
(Adult/Children /Youth)
Revision Date
Functional Area:
Chart Review –
Non-Hospital Services
Approved By: (Signature on File) Signed version available upon request
Kathy Aposhian, RN
Program Manager, Quality Management
07-01-2014
PURPOSE:
The purpose of the Electronic Health Questionnaire (EHQ) is to provide an opportunity to review the client’s physical health history. In addition, the EHQ allows the Provider to determine if a referral to a
Primary Health Care Provider might be appropriate or warranted.
DETAILS:
Procedure:
1. The completed EHQ is part of the Electronic Health Record (EHR) in the Clinical Workstation
(CWS) as part of the client’s chart
2. The clinician/personal service coordinator is responsible for having a completed EHQ as part of the Electronic Health Record (EHR) for all clients upon admission to the Mental Health Plan (MHP)
Provider’s program, otherwise risk fiscal disallowance. Parents or caregivers may provide the clinician/personal service coordinator with information to complete the EHR.
3. The provider shall review the EHQ with the client, parent/caregiver to ensure that all areas are completed and accurate.
4. The EHQ must be completed at start of services within 60 days of the Provider Start Date.
5. The EHQ Update must be completed annually along with a request for re-authorization, as well as in conjunction with any transfer. The EHQ update may be completed upon a re-opening to the system if the last EHQ had been completed within last 6 months.
6. When current health concerns are evident, the provider refers the client to a Primary Health Care
Provider or the attending Psychiatrist for physical evaluation and documents this referral in the
Progress Notes.
7. The MHP prohibits inappropriate referrals to a primary care provider for clients who meet mental health services’ medical necessity criteria. Disputes should be referred to the appropriate county
MHP medical director or designee.
8. For legally emancipated Minors (age 15 and up) and minors in RCL placement or foster care ages
16 and up who are mature enough to participate in the services provided and are aware of their physical healthcare history the clinician/personal service coordinator shall complete the correct
C ore Assessment (children/TAY, adult) to enable the EHQ based on the client’s age range.
Page 1 of 5
PP-BHS-QM-10-25-Health Questionnaire 07-01-14

Required Reporting Items:
The following items must be addressed in the EHQ. These elements are part of the required MHP audit protocol and contract for a complete bio-psychosocial assessment.
1. Relevant physical health conditions must be identified and updated as appropriate with referral to a Primary Care Physician as needed or appropriate.
2. Allergies and adverse reaction(s) to medications, or lack of known allergies.
3. Child/Youth HQ must include pre-natal and peri-natal events and a complete developmental history.
GENERAL PROVISIONS:
Based on client’s age range, select the applicable HQ that better fits the client’s needs (Adult Health
Questionnaire and/or the Child/Youth Health Questionnaire). Legally emancipated Minors (ages 15 and up) and minors in RCL placement, or foster care ages 16 and up who are mature enough to participate in the services provided and are aware of their physical healthcare history, may opt for the completion of the Adult Health Questionnaire in lieu of the Child/Youth Health Questionnaire.
The Adult Health Questionnaire (AHQ) shall include the following information.
1. Date.
The date the form is completed. If it takes more than one day to complete the form, this date should reflect the date the form was started.
2. Gender.
Identify and select the appropriate client’s gender. Based on this selection, applicable information will be pre-populated by Avatar.
3. Last Colon Screening.
Indicate whether or not the client has ever had a Colon Screening.
4. Currently seeing a primary physician.
Identify with a “yes’ or “no” if the client is currently seeing by a primary physician.
5. Last Doctor Visit.
Indicate the date of the last doctor’s visit as reported by the client. In addition, specify whether or not there is history of Cancer in client’s immediate family.
6. ER visits.
Mark either “yes”, “none reported” to identify any ER visits conveyed by the client in the preceding
12 months.
7. Conditions.
Identify any known medical conditions that the client has ever experienced. Indicate the onset and details and describe the medical conditions and current treatment the client is getting.
8. Gender specific questions
Choose the client’s gender specific questions. Provide information describing any existing health conditions, dates (to the best knowledge of the client/caregiver) and current treatments.
9. Dental
Indicate whether “yes” or “no” the client ever visited the dentist, ever had oral surgery or has any dental problems, date of last visit.
Page 2 of 5
PP-BHS-QM-10-25-Health Questionnaire 07-01-14

10. Hearing
Indicate if the client has any hearing problems, whether or not the client has had a hearing test and the results.
11. Vision
Indicate if the client has any visual problems, date of the last exam and whether or not the client wears any type of corrective lenses, and any details on vision problems.
12. Caffeine and Tobacco
Indicate if the client uses any caffeine and/or tobacco and describe amount of caffeine intake, smoking habits, and solicit from client if is interested in a smoking cessation program.
The Child/Youth Health Questionnaire (CHQ) shall include the following information .
1. Date.
The date the form is completed. If it takes more than one day to complete the form, this date should reflect the date the form was started.
2. Sources of Information/Relationship/Phone
Identify the name of the person providing the information for the CHQ/Youth form, the relationship to the child and /or other source of information.
3. Last physical.
Provide information related to the child’s last physical exam, and provide with date if known.
4. Current length/height/weight.
Provide information related to the child’s current length, height and weight at time of completion of this form.
5. Physical growth on target
Solicit from the parent/caregiver information to describe if the child’s physical growth is on target.
Mark either “yes’ or “no”.
6. Immunizations up to date.
Indicate whether or not the child’s immunizations are up to date.
7. General medical conditions.
M ark either “yes”, “no”, or “unknown” to identify any known medical conditions or symptoms the child has ever experienced and comment or explain about any answer/questions related to: history of auto accident and/or injury, broken bones, accident prone, episodes of easy bruising, bleeding or any other medical problems or conditions and any family medical history.
8. Hospitalization.
Describe any ER visits and details. Recent hospitalizations and reasons the child has been hospitalized. Describe any surgeries providing details. Describe any NIC experiences and specifics. Describe past medical hospitalizations as appropriate.
9. Pregnancy Information
Indicated circumstances surrounding the mother’s health during pregnancy by addressing following areas: Describe if pregnancy was planned, Trimester prenatal care was started. Indicate the mother’s age at start of pregnancy and duration of pregnancy (months). Indicate if AOD exposure in-utero, and any complications of pregnancy. Describe if any trauma during pregnancy, and it was a premature birth. Describe the mother’s health or any known conditions that affected the mother during pregnancy. Describe any relevant comments on pregnancy planning. Mark
“unknown” if the information is not known and describe the rationale.
Page 3 of 5
PP-BHS-QM-10-25-Health Questionnaire 07-01-14

10. Labor/Delivery/Birth History
Describe the duration of labor, anesthesia or medication used; Child’s birth weight and length;
Amount of time mother and child spent in the hospital; Indicate whether or not the child was breast fed and for how long; and indicate any other difficulties or peculiarities related to the delivery, appearance or behavior at birth or during pregnancy. Describe any medication used during birth. Write down the name and address of the hospital.
11. Birthing Complications
Identify any known birthing complications. Comment and explain in detail any complications as needed.
12. Neonate
Identify any known problems during the first 30 days of life. Comment on pregnancy issues as needed.
13. Developmental History
Indicate the age in which each event occurred and explain if necessary.
14. Behavior
Identify any Infant/toddler behaviors known problems during the first 3 years of life. Comment or explain as needed.
15. Dental
Indicate whether or not the child has ever seen the dentist. Describe if child ever had oral surgery
(extractions). Enter date (if known) of last exam and or history of any dental problems.
16. Vision
Indicate if the child has any history of visual problems, the date of the last exam. Describe any details of visual problems. Enter date if know. Describe whether or not the child wears glasses or contacts lens.
17. Hearing
Indicate if the child has any history of hearing problems, and describe the details of hearing problems. Indicate whether or not the child has tubes in his/her ears and/or has chronic hear infections. Indicate whether or not the child has had a hearing test and the results. Describe if the child uses hearing aids.
REFERENCE(S)/ATTACHMENTS:

None
RELATED POLICIES:

QM-10-30 Progress Notes

QM-10-26 Core Assessment
Page 4 of 5
PP-BHS-QM-10-25-Health Questionnaire 07-01-14

DISTRIBUTION:
Enter X DL Name
X
X
Mental Health Staff
Mental Health Treatment Center
Adult Contract Providers
Children’s Contract Providers
X Alcohol and Drug Services
Specific grant/specialty resource
CONTACT INFORMATION:

Tiffany Greer, LCSW
Quality Management Program Coordinator
Adult and Children’s Program Liaison
GreerTi@SacCounty.net
Enter X DL Name
X DHHS Human Resources
PP-BHS-QM-10-25-Health Questionnaire 07-01-14
Page 5 of 5