Health Assessment Survey
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1 Health Assessment Survey Your health is important to us! Please take 10 minutes complete this Health Assessment Survey and return it to the IU Health Plans Health Assessment Survey Team using the enclosed prepaid, self-addressed envelope. By answering these questions, we can: - Connect you with a registered nurse Care Manager to help you feel your best - Help you find neighborhood resources to assist with daily living - Discuss your health goals and develop a care plan to help you achieve them - Help you get the medical tests and services you may need - Assist caregivers or family members who may be looking after you First Name: Last Name: Date of Birth (MM/DD/YYYY): IU Health Plans Member ID Number: Use blue or black ink pen only. Correct: Do not use pens with ink that soaks through the paper. Make solid marks that fill the response completely. Incorrect: Make no stray marks on this form. X 1. Who is filling out this form? Self Spouse Other 2. In general, compared to other people your age, would you say your health is: Poor Fair Good Very Good Excellent 1
2 3. With whom do you live? Alone Spouse Child(ren) Other Family Other 4. What is the highest grade you completed in school? Never Attended Elementary High School College Professional School 5. In the past 12 months, how many times did you go to a doctor s office or clinic? t at all One time Two or three times Four to six times More than 6 times 6. In the past 12 months, how many times have you been treated in the emergency room? ne 1 time 2 to 3 times More than 3 times 7. In the past 12 months, have you stayed overnight as a patient in a hospital or nursing home?, 1 time, 2 to 3 times, more than 3 times 2
3 8. How many different prescription medicines do you take on an average day? (Count the number of different medicines, not the number of pills you take? 0 1 to 4 5 to 8 9 or more 9. Do you need help taking the right dose of medicine at the right time? Someone helps me with my medicine I need assistance, please contact me 10. What type of transportation do you use most often? (Mark only one response) I drive a car Walk Wheelchair Van Friend or relative Bus Taxi I need assistance please contact me Other 11. In a typical week, my moderate physical activity (similar to a brisk walk) is: (Mark only one response) Less than 30 minutes 30 to 60 minutes 1 to 2 hours 2 to 2.5 hours More than 2.5 hours 12. Is there a friend, relative, or neighbor who could take care of you for a few days if necessary? 3
4 13. Do you have a lot of difficulty with, or are you completely unable to do the following daily activities? Lifting or carrying objects as heavy as 10 pounds, such as laundry, groceries, etc.? Preparing meals every day? Managing money (ex. keeping track of expenses or paying bills)? Walking within your home? 14. Over the last two weeks, how often have you been bothered by: Little interest or pleasure in doing things? Nearly every day Half of the days Several days t at all Refused N/A Feeling down, depressed, or hopeless? Nearly every day Half of the days Several days t at all Refused N/A 15. In the past 12 months, has someone close to you died? 16. If yes, whom have you lost? (Mark all that apply) Spouse or significant other Sister or other Child or children Friend(s), Roommate(s) Pet(s) Other Other family member 4
5 17. Today my weight is pounds; my height is 18. Have you fallen in the past 3 months? 19. Have you and your doctor ever talked about: Heart failure or CHF (for example: leg swelling, water on the lungs)? Atrial fibrillation or irregular heart rhythm? Heart attack? Stroke(s)? Emphysema or COPD? Diabetes? Cancer? Amputation? Colostomy? 5
6 20. Are you now receiving or have you had any of the following treatments? (Mark all that apply) Dialysis Liver transplant Pancreas transplant Cornea transplant Skin transplant Kidney transplant Heart transplant Lung transplant Blood thinner/anti-coagulent (Coumadin) Bone marrow transplant Stem cell transplant Intestine transplant Bone transplant Other transplant 21. Do you have an advance directive (living will)? 22. Would you like information on a living will sent to you? 23. Have you already completed and sent a personal representative designation form to us, which gives us permission to speak with a family member, friend, or caregiver regarding your care? Thank you for completing this Health Assessment Survey! Please use the enclosed pre-paid, self-addressed envelope to return this survey to the IU Health Plans Health Assessment Survey Team. 6
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A B O U T M E A B O U T M E I n t h i s s e c t i o n, y o u w i l l f i n d : Your important contacts Your medical history A place to list your medications A place to write down your questions A calendar