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*

Member's Name*

First Last

Error Message

Member Gender*

Member Gender *

Male
Female

Person Completing This Survey

Name*

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*

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?*

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?*

What Language Do You Prefer To Speak? *

English
Spanish
Other

Other:*

What Language Do You Prefer To Receive Member Mailing In?*

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?*

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?*

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?*

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?*

Please check all that apply.

Other:*

Pregnancy Due Date:*

Would You Like Help In Managing Your Use of Alcohol or Substances?*

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?*

Are You Active In Treatment With A Medical Doctor or Specialist? *

Yes
No

Are You Active In Treatment With A Psychiatrist, Therapist or Counselor?*

Are You Active In Treatment With A Psychiatrist, Therapist or Counselor? *

Yes
No

How Many Prescription(s) Medications Do You Take Daily?*

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?*

In General How Would You Rate Your Overall Mental Health?*

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?*

Are You Homeless? *

Yes
No

Do You Have Difficulty Doing The Following Activities?

Bathing/Person Hygiene*

Bathing/Person Hygiene *

Yes
No

Getting Dressed Or Undressed*

Getting Dressed Or Undressed *

Yes
No

Feeding Yourself*

Feeding Yourself *

Yes
No

Using The Toilet*

Using The Toilet *

Yes
No

Getting In or Out of Chairs or Bed*

Getting In or Out of Chairs or Bed *

Yes
No

Walking*

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?*

Have You Fallen In The Last Year? *

Yes
No

How Many times?*

How Many times? *

1 Fall
2 Or More Falls

Were You Injured In Your 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?*

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*

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?*

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?*

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?*

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.

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