INITIAL HEALTH SCREENING QUESTIONNAIRE
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- Aubrey Powell
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1 Welcome to. Now that you are a member, we ask that you please fill out this form. It will help us understand your needs and how to best support you with programs and services. If you need help completing this form, please call our Rapid Response and Outreach Team at and a health plan representative will help you. INITIAL HEALTH SCREENING QUESTIONNAIRE CONTACT INFORMATION First name: M.I.: Last name: Address: City: State: ZIP code: Phone (Best number to reach you): Date of birth: LANGUAGE PREFERENCES Which language is most comfortable for you to speak about your health? English. Bosnian. Somali. Russian. Spanish. French. Arabic. German. Vietnamese. Other: Which language is most comfortable for you to read about your health? English. Bosnian. Somali. Russian. Spanish. French. Arabic. German. Vietnamese. Other: ETHNICITY AND RACE What is your ethnicity? Hispanic. If Hispanic or Latino, what is your country of origin? Non-Hispanic. Other: How do you describe your race? American Indian or Alaskan Native. Middle Eastern or North African. Native Hawaiian or Pacific Islander. Decline to state. Black or African American. Asian. White or Caucasian. Other: New Member Health Risk Assessment 1
2 Fill out these questions to help us better serve you. Health Risk Assessment questions At (Prestige), we know that health is more than what happens at your doctor s office. We would like to ask you some questions about your everyday needs. Based on your answers, someone from Prestige may contact you to discuss resources in your community. This information is private and protected like all of your health information, and all questions are optional. New Member Health Risk Assessment 2
3 Fill out these questions to help us better serve you. 1. Can you tell me the last grade you finished in school? No high school. Some high school. High school graduate. GED or high school equivalency. Finished vocational or trade program. Some college. College. Graduate or higher. 2. It can be challenging to understand when people at the doctor s office talk to you about your health. Do you ever get confused answering or asking questions about your health at appointments? Yes. Please check all that apply: Understanding my doctor s instructions. Reading my doctor s instructions. Understanding how to take medications. Understanding medical terms. Understanding lab results and test results. Other: No. 3. Sometimes it can be challenging to get transportation for your everyday needs. Have you had trouble getting rides for your health needs in the past four weeks? This can be a ride to the doctor or to get your medicine. What about going to the food store or to work? (Select all that apply). Yes, I have had trouble getting to the doctor or getting my medicine. Yes, I have had trouble getting other places I need to go. No. New Member Health Risk Assessment 3
4 Fill out these questions to help us better serve you. 4. It can be stressful to have trouble with paying bills and getting everyday things that you need. Over the past year, have you had trouble with any of the following items: a. Getting food for your family regularly? Yes. b. Paying your utilities bill (such as heating or electrical)? Yes. c. Getting the clothing you or your family need? Yes. d. Getting child care when you need to go to a doctor s appointment? Yes. e. Paying your phone bill? Yes. f. Getting everyday items you need (such as diapers, shampoo, blankets, and mattresses)? Yes. g. Trouble with something else? 5. Having shelter is an important part of your health. Can you tell me about your housing today? I have housing. I have housing, but I am worried about losing it. I don t have housing. 6. Who is completing the survey? Member. Parent or guardian. Other. Name of parent or guardian or other: New Member Health Risk Assessment 4
5 7. Are you pregnant? Yes. No. 8. In general, would you say your health is: Excellent. Very good. Good. Fair. Poor. 9. Do you or your child have any illnesses? Asthma. Diabetes. High blood pressure or cholesterol. Seizures or convulsions. Behavioral health. Sickle cell disease. Attention deficit hyperactivity disorder. Other: 10. Are you (or your child) having a problem going to see your doctor or specialist for a visit? Yes. No. I don t have a doctor I see regularly. 11. What transportation do you (or your child) usually use for medical appointments or services? Drive myself. Taxi. Caregiver or friend. Public transportation. Ambulance. No reliable transportation. Other: 12. Do you (or your child) take any medications? New Member Health Risk Assessment 5
6 13. If yes, do you (or your child) need help getting your medications? 14. Do you (or your child) use any tobacco products? No. Cigarettes or cigars. Smokeless tobacco (chewing tobacco, pipes, e-cigarettes, vapes). 15. Are you (or your child) around people who smoke tobacco products? 16. Do you (or your child) have any problems with walking, bathing, dressing, or using the toilet? 17. Do you (or your child) use any medical equipment? List medical equipment: 18. If yes, do you (or your child) need assistance in getting equipment, supplies, or home care items? 19. Are you (or your child) currently receiving any behavioral health services? 20. Would you (or your child) like to receive help with behavioral health services? 21. Do you (or your child) see a dentist? Name of dentist: 22. Do you feel that your (or your child s) illness or condition is not under control? New Member Health Risk Assessment 6
7 Thank you for completing our health assessment! This information will help us provide you the best possible care. We will keep your information private. Please return this form in the postage-paid return envelope or send to: P.O. Box 7181 London, KY You may also fax the completed form to If you have any questions concerning this form, please call Member Services at New Member Health Risk Assessment 7
8 This information is available for free in other languages. Please contact our customer service number at or TTY/TDD , 24 hours a day, 7 days a week. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese con nuestro número de servicio al cliente al o TTY/TDD , las 24 horas del día, los 7 días de la semana. Enfòmasyon sa a disponib gratis nan lòt lang. Tanpri rele sèvis kliyan nou annan nimewo oswa pou moun ki pa tande byen, 24 sou 24, 7 sou 7. PRES M1012_1708
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