Home | Member Health Assessment Member Health Survey "*" indicates required fields Name* Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Middle Last Suffix Member Number*Include the leading zero for 6-digitsPhoneEmail Date of Birth* MM slash DD slash YYYY MM/DD/YYYYWhat is your current height?*Measurements in Ft/InWhat is your current weight?*Weight in the lbsIn general, would you say your health is:* Poor Fair Good Very Good Excellent When was the last time you saw your primary care doctor?* Less than 6 months ago 6-12 months ago More than a year ago Have you had 3 or more emergency room (ER) visits in the last 12 months?* Yes No Have you been hospitalized 2 or more times in the past 12 months?* Yes No Do you currently drink wine, beer, or other alcoholic beverages on a daily basis?* Yes No Do you smoke cigarettes, use tobacco, or any nicotine products currently or in the last 6 months?* Yes No Do you live alone?* Yes No Do you have help at home (if needed)?* Yes No Do you need help to get around inside or outside the home?* Yes No Do you use a cane, wheelchair, or walker?* Yes No Have you fallen 2 or more times in the last 12 months?* Yes No In the past 4 weeks, have you been feeling down, hopeless, or have little interest in doing things?* Yes No What health conditions do you have currently, or had in the past?* Allergies Asthma Bowel and Gastrointestinal Conditions Cancer Colds and Flu COPD (Chronic Obstructive Pulmonary Disease) Diabetes Disease and Disease Prevention Down Syndrome, Autism and Developmental Delays Epilepsy Fatigue and Sleep Heart Health and Stroke Hepatitis HIV Infectious Diseases Joints and Spinal Conditions Kidneys Lungs and Respiratory Conditions Multiple Sclerosis (MS) Obesity Skin, Nails and Rashes Thyroid None Other What other health conditions do you currently have, or had in the past?*Surgeries and/or Medical ProceeduresHave you ever had surgery or any medical procedures?* Yes No Please list all of your prior surgeries and/or medical procedures: Type of surgery or medical procedure Date Performed Actions Edit Delete There are no Surgeries/Medical Procedures. Add Surgery/Medical Procedure Maximum number of surgeries/medical procedures reached. Medications and/or SupplementsAre you currently taking any medications or supplements?* Yes No Do you take your medications as ordered by your doctor?* Yes No Please list all of your current medication(s) and/or supplement(s): Name of Medication Dosage Frequency Actions Edit Delete There are no Medications. Add Medication Maximum number of medications reached. Consent* I hereby certify that, to the best of my knowledge, the provided information is true and accurate. Signature*CommentsThis field is for validation purposes and should be left unchanged. Δ
