BEH AVIOR AL HEAL TH
Residential Substance Abuse Physical Exam Form
APPLICANT’S NAME _____________________________________ DATE OF BIRTH__________________
The above applicant is going to participate in a residential treatment program for alcohol and/or other chemical dependency.
We are asking you to examine this individual to give medical clearance for his/her admission to this facility. We would
appreciate your candid appraisal of this applicant’s health. If you are aware of any health reasons why this participant should
not be involved in our program, please specify.
BP _________/__________ Temp:___________ Resp:_____________
EXERCISE TOLERANCE TEST: Resting Pulse________ After 1 minute exercise_________
After 2 minutes exercise________
Vital signs within normal limits? Yes No Signs and symptoms of malnutrition? Yes No
Current alcohol or drug intoxication? Yes No
Diabetes? Yes No Insulin Dependent? Yes No Epilepsy? Yes No Hypoglycemia? Yes No
Obesity (to the extent of interfering with moderate exercise)? Yes No
Chronic Renal disease, which might be aggravated by dehydration or moderate exercise? Yes No
Arthritis, which might be aggravated by moderate exercise? Yes No
If female, results of pregnancy test: Pregnant Not Pregnant
Screened for Hepatitis A, B or C? Yes No If Yes, was the patient positive for Hepatitis? Yes Type _________ No
Recent TB Test? Yes No If Yes: Date______________________ Results__________________________________________
If applicant is currently taking medication, please list condition, type of medication and dose (if none, specify none):
Please address any selection above or any "Yes" answer on which would restrict the client’s participation in residential treatment --please
state, what, if any, accommodation would be necessary for client to participate in the program including moderate exercise (if more space
is needed, please use the reverse side of this form)
GENERAL APPRAISAL (check appropriate box):
Approval – I find no conditions which I consider incompatible with a residential treatment program which
includes moderate exercise. To the best of my knowledge, this client is not at risk for acute withdrawal from
Disapproval – This applicant has conditions, which in my opinion, clearly constitute unacceptable hazards to
his/her health and safety if required to participate in a residential treatment program which includes a moderate
M.D. Signature ______________________________________________________________Date________________________________
Residential Substance Abuse Physical Exam Form – MG – 10-08
BEH AVIOR AL HEAL TH
Residential Substance Abuse Client Health Questionnaire
APPLICANT’S NAME: ________________________________________________ DATE OF BIRTH:________________
Height ________ Weight______ Frame_______
Please answer the following questions by checking the appropriate Yes/No box; explain any "Yes" answers on the reverse
side of this form. Underline any questions you do not understand:
1. Do you have an ongoing chronic illness?
2. Have you ever been hospitalized overnight?
3. Have you ever had surgery?
4. Are you currently taking any prescription or nonprescription (over-the-counter) medications
or pills or using an inhaler?
5. Have you ever taken (or are you currently taking) any supplements or vitamins to help you
gain or loose weight or improve your performance?
6. Do you have any allergies (for example to pollen, medicine, food, or stringing insects)?
7. Have you had high blood pressure or high cholesterol?
8. Have you ever had a stroke or blood clot?
9. Have you ever been told you have a heart murmur?
10. Has any family member or relative died of heart problems or sudden death before age 50?
11. Do you have any current skin problems (for example itching, rashes, acne, warts, fungus, or
12. Have you ever had a head injury of concussion?
13. Have you ever been knocked out, become unconscious, or lost your memory?
14. Have you ever had a seizure?
15. Do you have frequent or severe headaches?
16. Have you ever had numbness or tingling in your arms, hands, legs, or feet?
17. Do you cough, wheeze, or have trouble breathing during or after activity?
18. Do you have asthma?
19. Do you have seasonal allergies that require medical treatment?
20. Have you had any problems with your eyes or vision?
21. Do you wear glasses, contacts, or protective eyewear?
22. Do you have any hearing or other ear problems?
23. Do you have abdominal pain (for example hernia or problematic menstrual cramping)
24. Do you have Edema?
Please list any medications, vitamins, or supplements you have taken recently or regularly:
Please list any medical conditions that were not addressed above:
___________________________________________________will follow and provide care for the medical conditions listed above
Physician(s) name and Phone Number while I attend residential treatment.
I certify that the above information is accurate to the best of my knowledge. I have a one month supply of medications and/or a way to pay
for my medication.
Client’s Signature Date
Residential Substance Abuse Client Health Questionnaire – MG – 10-08