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Health Survey

Health Survey

Health Survey Form

Health Survey

In general, how would you rate your health?

Excellent

Very Good

Good

Fair

Poor

Unknown

Free Text

What health conditions do you currently have?

Hypertension (high blood pressure)

Yes

No

Depression

Yes

No

Anxiety

Yes

No

Hyperlipidemia (high cholesterol)

Yes

No

Obesity

Yes

No

Anemia

Yes

No

Diabetes

Yes

No

Kidney Disease

Yes

No

Option 3

Arthritis

Yes

No

Dementia/Alzheimer's Disease

Yes

No

Free Text

Has lack of transportation kept you from:

Medical appointments or from getting medication?

Yes

No

Non-medical meetings, appointments, work, or from getting things you need?

Yes

No

What is your living situation today?

I have a place to live

I have a place to live today, but I am worried about losing it in the future.

I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandon building, bus or train station, or in a park.)

Do you always feel safe in your home and around all the people in your life?

Yes

No

Unknown

Based on your household, within the past 12 months, have you worried your food would run out before you got money to buy more?

Often True

Sometimes True

Never True

Based on your household, within the past 12 months, has the food you bought not lasted and you didn't have the money to get more?

Often True

Sometimes True

Never True

Over the past 2 weeks, how often have you been bothered by having little interest or pleasure in doing things?

Not at all

Several Days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless?

Not at all

Several Days

More than half days

Nearly every day

Do you need help with any of these actions?

Yes

No

Grooming?

Yes

No

Getting out of a chair?

Yes

N

Eating/feeding?

Yes

No

Bathing?

Yes

No

Dressing?

Yes

No

Using the toilet?

Yes

No

Free Text

Do you need help with any of these actions?

Shopping?

Yes

No

Food preparation?

Yes

No

Using the telephone?

Yes

No

Housekeeping

Yes

No

Laundry?

Yes

No

Transportation?

Yes

No

Taking responsibility for your medications?

Ye

No

Your ability to handle finances?

Yes

No

Do you have a written life plan document, such as an advance directive, living will, or medical or durable power of attorney for health care, combined directives, physician or medical order for life-sustaining treatment or scope of treatment?

Y

No, but I would like to discuss this

No, and I don't wish to discuss this.

During the last month, have you had pain that interfered with completion of housework or your ability to work outside the home?

Yes

No

Please rate your worst pain over the last 5 days on a zero to ten scale, with zero being no pain and ten as the worst pain you can imagine.

0 - No Pain

1-3 Mild Pain

4 to 6 - Moderate Pain

7-10 - Severe Pain

In the past year, how many times have you fallen?

Free Text

What vaccinations have you had?

COVID?

Yes

No

Flue?

Yes

No

Pneumonia?

Ye

No

Tetanus, Diphtheria, Pertussis (TDAP)?

Yes

No

Shingles?

Yes

No

When was the last time you saw a dentist?

In the last 6 months

In the last 12 months

In the last 2 years

More than 2 years ago

Have never seen a dentist

Unknown

During the past year, how often did you have 5 or more alcoholic drinks in one day?

Never

Once or twice

Monthly

Weekly

Daily or almost daily

Unknown

During the past year, how often did you use tobacco products?

Never

Once or twice

Monthly

Weekly

Daily or almost daily

Unknown

What is the current year?

How would you prefer to communicate with your health plan's Care Team?

Phone Call

Secure messaging/chat

Video call

Email

No response

Free Text

Thank you for completing these important health questions. Medicare requires that you complete this survey annually or if you change plans, you may be asked to complete this survey again next year. If you have questions about this survey or your health plan benefits, please call the customer service phone number on the back of your member ID card.

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Family Matters Insurance Agency

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Mon - Sat: 7am - 7pm

Sun: Closed

or

Anytime, Any Day by Appointment

2400 W Pawnee St, Suite 112, Wichita KS 67213

Todd@FamilyMattersInsurance.com

(316) 444-0855 | Fax : 316-281-4777

Family Matters Insurance Agency

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