Member Health Survey This information will not affect your eligibility and will only be shared by those authorized to see it. If you are completing this survey on behalf of the member, please answer all of the following questions from the member's perspective.Member ID#* Member's DOB* MM slash DD slash YYYY Member's Name* First Last Error Message Member Gender* Male Female Person Completing This SurveyName* First Last Phone Number*Relationship Of The Person Completing Survey* List Phone #'s To Best Reach The Member Or Member's Parent/Guardian Regarding Health Needs* Would You Like Us To Update Your Mailing Address* Yes No Member's Mailing Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Is The Member Covered Under Any Other Active Health Insurance?* Yes No If Yes, List:*Policy Name:Policy Number: What Language Do You Prefer To Speak?* English Spanish Other Other:* What Language Do You Prefer To Receive Member Mailing In?* English Spanish Other Other:* What Is Your Race?* White Black Asian Native Hawaiian or Pacific Islander Hispanic or Latino American Indian or Alaska Native Other Prefer Not to Answer Please check one or more.Other:* How Many Times Have You Been Admitted To The Hospital In The Last 6 Months?* None 1-3 Time(s) 4-9 Times 10 Or More Times How Many Times Have You Been To The Emergency Room In The Last 6 Months?* None 1-3 Time(s) 4-9 Times 10 Or More Times How Many Times Have You Been Admitted To A Nursing Home, Skilled Nursing or Medical Rehabilitation Facility In The Last 6 Months?* None 1-3 Time(s) 4-9 Times 10 Or More Times Do You Have Any Of The Following Condition(s) That You're Aware Of?* Health Failure Asthma Diabetes COPD or Emphysema Depression Anxiety Disorder Bipolar Disorder Schizophrenia Post Traumatic Stress Disorder (PTSD) Pregnant Alcohol or Substance Use or Abuse Other Please check all that apply.Other:* Pregnancy Due Date:* Would You Like Help In Managing Your Use of Alcohol or Substances?* Yes No Are You Active In Treatment With A Medical Doctor or Specialist?* Yes No Are You Active In Treatment With A Psychiatrist, Therapist or Counselor?* Yes No How Many Prescription(s) Medications Do You Take Daily?* 1-4 5-9 10 or more Not Answered In General How Would You Rate Your Overall Health?* Excellent Very Good Good Fair Poor In General How Would You Rate Your Overall Mental Health?* Excellent Very Good Good Fair Poor Who Do You Live With?* Alone Parent/Guardian Spouse or Partner Friend or Family Member Other Please check all that apply. Other:* Are You Homeless?* Yes No Do You Have Difficulty Doing The Following Activities?Bathing/Person Hygiene* Yes No Getting Dressed Or Undressed* Yes No Feeding Yourself* Yes No Using The Toilet* Yes No Getting In or Out of Chairs or Bed* Yes No Walking* Yes No Do You Have Someone Who Helps You With These Activities?* Family Other (Not Family) No One Please check all that apply.Have You Fallen In The Last Year?* Yes No How Many times?* 1 Fall 2 Or More Falls Were You Injured In Your Falls?* Yes No Over The Last 2 Weeks, How Often Have You Been Bothered By Things or Had Little Interest or Pleasure In Doing Things or Feeling Down, Hopeless or Depressed?* Several Days More Than Half The Days Nearly Everyday Prefer Not To Answer Do You Now Smoke Cigarettes or Use Tobacco Every Day, Some Days or Not At All* Every Day Some Days Prefer Not To Answer Please check one.Have You Been Released From A Correctional Facility In The Last 6 Months?* Yes No Prefer Not To Answer For adults 18 years of age or older.Do You Need Assistance With Community Resources Regarding Food, Housing Utilities or Transportation?* Yes No Would You Like Us To Send You A Community Resource Mailing?* Yes No What Do You Consider Your Personal Strong Points and Goals?Required for Integrity and Unity members only.CAPTCHA CommentsThis field is for validation purposes and should be left unchanged.