Medicare Health Risk Assessment Questionnaire

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1 Medicare Health Risk Assessment Questionnaire Instructions: Please complete and return it in the self-addressed stamped envelope provided. If you have questions or need help completing the questionnaire, call our toll free line at Monday-Friday 9am 5 pm. ONECare uses this questionnaire to assist in assessing your health status. Your Name: Street Address: City, Zip Code: Day Phone: ONECare ID#: Please check the appropriate box that answers the questions below and write any additional pertinent information that will help us meet your needs better. 1. Did you receive your ONECare new member packet and ID Card? 2. What is your primary language? 3. Survey completed by: o Member o Other 4. Do you know who your Primary Care Physician (PCP) is? 5. If yes, what is the name of your PCP? 6. When was the last time you saw your PCP? _ 7. Do you see any specialty doctors? 8. If yes, please list specialty or specialties? 9. Do you routinely get a flu shot every year? 10. Have you had a pneumonia shot in the past 11. Are you currently experiencing any hearing problems? Page 1 of 6

2 12. If yes, please explain: 13. Have you had a hearing exam? 14., Have you ever had a colonoscopy? 15. If you have had a colonoscopy, date of service? 16. Where did you have the colonoscopy? 17. Female--, have you had a pelvic exam and a PAP smear test in the last year? 18. What was the date of your most recent PAP smear? 19. Have you had an abnormal PAP smear? 20. When was your last mammogram? Date 21. Have you had a Prostate exam?? 22. What was the date of your last Prostate exam? 23. Have you been to an emergency room in the last 6 months? 24. If yes, how many times? o 1-2 times o 3-4 times o 5 or more times 25. If yes give reasons? 26. Have you stayed overnight in a hospital in the past 6 months Page 2 of 6

3 27. If yes, how many times? o 1-2 times o 3-4 times o 5 or more times 28. If yes, give reason(s)? 29. Have you been in a skilled nursing facility in the past 6 months? 30. If yes, which facility? 31. If yes, give reason? 32. Prescription medication you are currently taking? Page 3 of 6

4 **If more, please include a separate sheet with information** 33. Over-the-counter products (vitamins, supplements, herbal, other) you are currently taking? Name of product: Name of product: Name of product: 34. Names of any alternative treatment you are taking, prescription or non-prescription. 35. Do you use any special equipment because of a disability or health problem such as walker or a cane? Please list 36. Do you use any medical supplies at home such as diabetic supplies or dressing supplies? Please list. o 37. Are you currently receiving any services from an agency such as home health or Meals on Wheels? Please list. o Page 4 of 6

5 38. Are you currently being treated for any health conditions such as breathing problems or heart problems? Please list. 39. Do you have Diabetes? 40. Do you check your blood sugars? 41. Have you had a vision exam within the last year? 42. If yes, what was the date of service? 43. Are you currently experiencing any vision problems? 44. Have you had a Glaucoma Eye Screen in the last 12 months 45. Do you have or have you been treated for asthma? 46. Do you use an Inhaler? 47. Do you have or have you had chronic pain such as back pain? Yes No 48. What is your level of pain? On a scale of 1-10 with 1 being very little pain and 10 being the most severe pain. : 49.. Do you live alone? If no, with whom do you live? 50? Do you feel you need help getting the care you need? 51. Are you able to perform your activities of daily living such as bathing and dressing? Please list those activities that you need some help performing the activity If you receive help with any of the activities in the above question, who is the helper? Name: Relationship: Phone number: 53. May we contact your helper/caregiver? Page 5 of 6

6 54. Have you fallen in the past 6 months? 55. If yes, how many times? o Once o 1-2 times o 3-4 times o 5-6 times o Over 6 times 56. Do you currently have any open wounds, bed sores? 57. Are you enrolled in a behavioral health program? o If yes, which one? o What condition(s) are you being treated for? 58. Are you depressed or ever thought about hurting yourself? Yes No 59. Are you having a problem with Alcohol or Drugs? Yes No 60. Do you drink alcohol (beer, wine, hard liquor)? o # beers per day o # wine per day o # hard liquor per day 61. Do you smoke? o If yes, how much do you smoke? 62. Do you have advanced directives? 63. Is there anything else you would like us to know about you? I understand that this information may be shared with my physician. Signature Today s Date Thank you for your time in completing this questionnaire Page 6 of 6

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