The Health Questionnaire provides a reliable and valid assessment of physical health. It can detect improvements in physical health following addiction treatment. The scale has been used with male and female adult and elderly samples from clinical and non-clinical populations

Brodman, K

Erdmann, AJ

Lorge, I

Wolff, HG

National Documentation Centre on Drug Use

Health QuestionnaireINSTRUCTIONS: If you can answer YES to the question asked, put a circle around theYes.If you have to answer NO to the question asked, put a circle around the No.Answer all questions. If you are not sure, guess.A1. Do you need glasses to read? YES      NO2. Do you need glasses to see things at a distance? YES      NO3. Has your eyesight often blacked out completely? YES      NO4. Do your eyes continually blink or water? YES      NO5. Do you often have bad pains in your eyes? YES      NO6. Are your eyes often red or inflamed? YES      NO7. Are you hard of hearing? YES      NO8. Have you ever had a bad running ear? YES      NO9. Do you have constant noises in your ears? YES      NOB10. Do you have to clear your throat frequently? YES      NO11. Do you often feel a choking lump in your throat? YES      NO12. Are you often troubled with bad spells of sneezing? YES      NO13. Is your nose continually stuffed up? YES      NO14. Do you suffer from a constantly running nose? YES      NO15. Have you at times had bad nose bleeds? YES      NO16. Do you often catch severe colds? YES      NO17. Do you frequently suffer from heavy chest colds? YES      NO18. When you catch a cold, do you always have to go to bed? YES      NO19. Do frequent colds keep you miserable all winter? YES      NO20. Do you get hay fever? YES      NO21. Do you suffer from asthma? YES      NO22. Are you troubled by constant coughing? YES      NO23. Have you ever coughed up blood? YES      NO24. Do you sometimes have severe soaking sweats at night? YES      NO25. Have you ever had a chronic chest condition? YES      NO26. Have you ever had T.B. (Tuberculosis)? YES      NO27. Did you ever live with anyone who had T.B.? YES      NOC28. Has a doctor ever said your blood pressure was too high? YES      NO29. Has a doctor ever said your blood pressure was too low? YES      NO30. Do you have pains in the heart or chest? YES      NO31. Are you often bothered by thumping of the heart? YES      NO32. Does your heart often race like mad? YES      NO42. Are you troubled by bleeding gums? YES      NO43. Have you often had severe toothaches? YES      NO44. Is your tongue usually badly coated? YES      NO45. Is your appetite always poor? YES      NO46. Do you usually eat sweets or other food between meals? YES      NO47. Do you always gulp your food in a hurry'? YES      NO48. Do you often suffer from an upset stomach? YES      NO49. Do you usually feel bloated after eating? YES      NO50. Do you usually belch a lot after eating? YES      NO51. Are you often sick to your stomach? YES      NO52. Do you suffer from indigestion? YES      NO53. Do severe pains in the stomach often double you up? YES      NO54. Do you suffer from constant stomach trouble? YES      NO55. Does stomach trouble run in your family? YES      NO56. Has a doctor ever said you had stomach ulcers? YES      NO57. Do you suffer from frequently loose bowel movements? YES      NO58. Have you ever had severe bloody diarrhea? YES      NO59. Were you ever troubled with intestinal worms? YES      NO60. Do you constantly suffer from bad constipation? YES      NO61. Have you ever had piles (rectal hemorrhoids)? YES      NO62. Have you ever had jaundice (yellow eyes and skin)? YES      NO63. Have you ever had serious liver or gall bladder trouble? YES      NOE64. Are your joints often painfully swollen? YES      NO65. Do your muscles and joints constantly feel stiff? YES      NO66. Do you usually have severe pains in the arms or legs? YES      NO67. Are you crippled with severe rheumatism (arthritis)? YES      NO68. Does rheumatism (arthritis) run in your family? YES      NO69. Do weak or painful feet make your life miserable? YES      NO70. Do pains in the back make it hard for you to keep up with your work? YES      NO71. Are you troubled with a serious bodily disability or deformity? YES      NOF72. Is your skin very sensitive or tender? YES      NO73. Do cuts in your skin usually stay open a long time? YES      NO74. Does your face often get badly flushed? YES      NO75. Do you sweat a great deal even in cold weather? . YES      NO76. Are you often bothered by severe itching? YES      NO77. Does your skin often break out in a rash? YES      NO78. Are you often troubled with boils? YES      NOG89. Have you at times had a twitching of the face or head? YES      NO90. Did you ever have a fit or convulsion (epilepsy)? YES      NO91. Has anyone in your family ever had fits or convulsions (epilepsy)? YES      NO92. Did you bite your nails badly? YES      NO93. Are you troubled by stuttering or stammering? YES      NO94. Are you a sleep walker? YES      NO95. Are a bed wetter? YES      NO96. Were you a bed wetter between the ages of 8 and 14? YES      NOH - FEMALES97. Have your menstrual periods usually been painful? YES      NO98. Have you often felt weak or sick with your periods? YES      NO99. Have you often had to lie down when your periods came on? YES      NO100. Have you usually been tense or jumpy with your periods? YES      NO101. Have you ever had constant severe hot flashes and sweats? YES      NO102. Have you often been troubled with vaginal discharge? YES      NO103. Do you have to get up every night and urinate? YES      NO104. During the day, do you usually have to urinate frequently? YES      NO105. Do you often have severe burning paw when you urinate? YES      NO106. Do you sometimes lose control of your bladder? YES      NO107. Has a doctor ever said you had kidney or bladder disease? YES      NOH - MALES97. Have you ever had anything seriously wrong with your genitals (privates)? YES      NO98. Are your genitals often painful or sore? YES      NO99. Have you ever had treatment for your genitals? YES      NO100. Has a doctor ever said you had a hernia (rupture)? YES      NO101. Have you ever passed blood while urinating (passing water)? YES      NO102. Do you have trouble starting your stream when urinating? YES      NO103. Do you have to get up every night and urinate? YES      NO104. During the day, do you usually have to urinate frequently? YES      NO105. Do you often have severe burning pain when you urinate? YES      NO106. Do you sometimes lose control of your bladder? YES      NO107. Has a doctor ever said you had kidney or bladder disease? YES      NOI108. Do you often get spells of complete exhaustion or fatigue? YES      NO109. Does working tire you out completely? YES      NO110. Do you usually get up tired and exhausted in the morning? YES      NO111. Does every little effort wear you out? YES      NO112. Are you constantly too tired and exhausted even to cat? YES      NO113. Do you suffer from severe nervous exhaustion? YES      NO114. Does nervous exhaustion run in your family? . YES      NO122. Are you always ill and unhappy? YES      NO123. Are you constantly made miserable by poor health? YES      NOK124. Did you ever have scarlet fever? YES      NO125. As a child, did you have rheumatic fever, growing pains or twitching of the limbs? YES      NO126. Did you ever have malaria? YES      NO127. Were you ever treated for severe anemia (thin blood)? YES      NO128. Were you ever treated for “bad blood” (venereal disease)? YES      NO129. Do you have diabetes (sugar disease)? YES      NO130. Did a doctor ever say you had a goiter (in your neck)? YES      NO131. Did a doctor ever treat you for tumor or cancer? YES      NO132. Did you suffer from any chronic disease? YES      NO133. Are you definitely under weight? YES      NO134. Are you definitely over weight? YES      NO135. Did a doctor ever say you had varicose veins (swollen veins) in your legs? YES      NO136. Did you ever have a serious operation? YES      NO137. Did you ever have a serious injury? YES      NO138. Did you often have small accidents or injuries? YES      NOL139. Do you usually have great difficulty in falling asleep or staying asleep? YES      NO140. Do you find it impossible to take a regular rest period each day? YES      NO141. Do you find it impossible to take regular daily exercise? YES      NO142. Do you smoke more than 20 cigarettes a day? YES      NO143. Do you drink more than six cups of coffee or tea a day? YES      NO144. Do you usually take two or more alcoholic drinks a day? YES      NONote.  The male and female versions of the HQ are identical except for section H.

Health Questionnaire. Outcomes measurement tool:  personal circumstances & needs – physical health.

https://www.drugsandalcohol.ie/26811/1/Health%20Questionnaire.pdf

Health Questionnaire. Outcomes measurement tool: personal circumstances & needs – physical health.

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National Documentation Centre on Drug Use