HEALTH ASSESSMENT SURVEY – Hayden’s Pharmacy

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By selecting "I agree" below, you are agreeing with the information supplied for the Hayden's Pharmacy Clinical Survey.

Taking part of this survey is voluntary. The health information that is received will allow our team to improve your wellbeing and encourage healthy habits. The information does not diagnosis illnesses or health problems. It does not replace any medical or treatment advice from the patient's healthcare provider.

All answers are private and kept confidential. This information may be shared with healthcare team members to help improve the patients health. The healthcare plan created and summary reports maybe shared with hospitals, healthcare providers, and pharmacists. These reports will not include your personal information only your medical information submitted. *

I AGREE

PLEASE ANSWER AND COMPLETE THE FOLLOWING HEALTH SURVEY QUESTIONS:

Patient Last name *

Patient First Name *

Patient Date of Birth *

Email address: *

Patient's Cell Phone *

Who is completing this form? *

Myself

A relative of the patient

A designated caregiver

Other

What is your / the patient gender ? *

Male

Female

Prefer not to answer

What is your / the patient's ethnicity? *

White

Black or African American

Hispanic or Latino

Asian

Native American / Native Alaskan

Native Hawaiian / Pacific Islander

Other

Prefer not to answer

Who is completing this form? *

Myself

A relative of the patient

A designated caregiver

Other

Patient's Height (in feet & inches)? *

Patient's Weight (in pounds)? *

PATIENT HEALTH SURVEY FOR CLINICAL SERVICES