Health Risk Assessment Form Community First Health Plans Medicare Advantage HMO Members are encouraged to complete the following Health Risk Assessment, also called a Health Risk Screening. Responses are confidential and will help Community Services provide the medical, behavioral, cognitive, and social services and support needed to stay healthy. If you need help completing this assessment, please call Member Services at 1-833-434-2347.Member Name(Required) First Last Date of Birth(Required) Month Day Year Address(Required) Street Address City State / Province / Region ZIP / Postal Code Member Email Address(Required) Phone Number(Required)Are you pregnant?(Required) Yes No Not applicable Are you under the age of 18?(Required) Yes No What medications do you take?(Required)What medical conditions have you been told you currently have or had in the past?(Required) Heart Disease Heart Failure High Blood Pressure Cancer or Tumor COPD Asthma Diabetes Kidney Disease Liver Disease Depression Mental Health Issue Memory Problem Hearing Loss Vision Problems Pregnancy None Other If other, please describe:(Required)Do you need help with any of these daily activities?(Required) Bathing and grooming Dressing and undressing Eating or feeding yourself Moving yourself from chairs or beds Using the toilet Walking Preparing your meals Driving or Using public transportation Shopping Using the telephone Doing laundry Cleaning your home Managing your finances Managing your medications Making decisions about your health or treatment None Other If other, please describe:(Required)Do you have someone who can help you with daily activities?(Required) I do not need help I have enough help I would like more help Do any of these prevent you from getting the care you need?(Required) Transportation Housing Clothing Food Finances Employment Lack of support system Language barrier Cultural barrier Lack of motivation High level of stress Caregiver responsibilities Exposure to crime, violence, social disorder Residential isolation and/or other forms of discrimination Lack of access to emerging technologies Difficulty interacting with others Health beliefs and behaviors Other None If other, please describe:(Required)In the past 6 months, how many times have you been hospitalized and/or received care in an emergency room (ER)?(Required) None 1 time 2 or more times In the past 6 months, how many times have you fallen? None 1 time 2 or more times When was your last appointment with your primary care provider (PCP)?(Required)When is your next appointment with your PCP scheduled?(Required)In the past year did you have trouble remembering things?(Required) Yes No In the past year, how many times have you consumed alcohol?(Required) None Less than 1 or 2 drinks per week More than 1 or 2 drinks per week At least 1 drink per day 4 or 5 drinks per day In the past year, how many times have you used tobacco?(Required) None Less than 1 or 2 times per week More than 1 or 2 times per week At least 1 time per day 4 or 5 times per day What tobacco products do you use?(Required) None Cigarettes Cigars Chew/smokeless Vaping Other If other, please describe:(Required)In the past year, how many times have you used prescription drugs for non-medical reasons?(Required) None Less than 1 or 2 times per week More than 1 or 2 times per week At least 1 time per day 4 or 5 times per day In the past year, how many times have you used illegal drugs?(Required) None Less than 1 or 2 times per week More than 1 or 2 times per week At least 1 time per day 4 or 5 times per day Do you have any religious beliefs or cultural customs that may affect your medical care?(Required) Yes No If yes, please describe the Member's beliefs or cultural custom.(Required)Which of these community services do you need?(Required) Community Mental Health Medical condition support group Food bank, soup kitchen or delivered meals Self-help programs None Other If other, please describe:(Required)What's the highest level of education you have completed?(Required) Elementary Junior High High School Technical/Trade School Some college 2-year college degree 4-year college degree Graduate/Professional school Other Don't know/unsure I prefer not to answer If other, please describe:(Required)What type of home-setting do you currently live in?(Required) House/Apartment Car/Motorhome Group/Adult Home Homeless Motel/Hotel House Nursing Home/Assisted Living Shelter Skilled Nursing Facility (SNF) Don't Know/Unsure I prefer not to answer Other If other, please describe:(Required)Do you feel physically and emotionally safe where you currently live?(Required) Yes No Don't know/unsure If No, please describe:(Required)Do you have concern(s) that you will need medical care or services that are not covered by your Medicare and Medicaid benefits?(Required) Yes No If Yes, please describe:(Required)Have you named someone to make medical decisions for you if you are unable to do so?(Required) Yes, I have a Health Care Proxy, Power of Attorney, or Advance Directive No, but I would like more information on how to do it No, not needed or interested at this time How do you prefer written information from Community First Health Plans?(Required) The print size on this form is fine Large Print Braille How do you prefer spoken information from Community First Health Plans?(Required) Telephone In person American Sign Language (ASL) Teletypewriter (TTY) If by telephone, please provide preferred number:(Required)Are you satisfied with the services you are currently receiving?(Required) Yes No Don't know/unsure Not Applicable If No, please describe:(Required)Do you have additional needs that we have not discussed?(Required) Yes No Don't know/unsure If Yes, please describe:(Required)Are you interested in having a Community First Health Plans' nurse or social worker help you?(Required) Yes No If No, please tell us why:(Required)Do you want to be part of a team meeting with all your doctors and caregivers?(Required) Yes No Health Risk Assessment Completion Date(Required) Month Day Year Δ
