Health Status Assessment Form Step 1 of 4 25% Last Name* First Name* GenderGender IdentityMaleFemaleBirthdate MM slash DD slash YYYY Height Employer Member Number Home Phone NumberWork Phone NumberBest Time To Call Email* Preferred Method of ContactPreferred Method of ContactHome PhoneWork PhoneEmailCurrent Physician I give my permission for my Care Manager to speak with the following about my medical condition: Have you had a physician office visit for your condition at least once in the last 12 months? Yes No Date of Visit MM slash DD slash YYYY Have you ever had an evaluation by a specialist for your chronic condition? Yes No Date of Evaluation MM slash DD slash YYYY Have you had any inpatient hospitalizations in the last year? Yes No Have you had any emergency room/urgent care visits in the last year? Yes No Do you have your blood pressure checked at every physician office visit? Yes No What was your last blood pressure reading? Have you had a Flu Vaccination in the last 12 months? Yes No Flu Vaccination Date MM slash DD slash YYYY Have you had a Pneumonia Vaccination? Yes No Pneumonia Vaccination Date MM slash DD slash YYYY Do you have any new medications? Yes No Please list any new medicationsPlease include the medication name, dosage, how often you take the medication, and the condition you are treating. Be sure to include over the counter medications. Do you exercise at least 30 minutes 3 or more times a week? Yes No Are you following a prescribed diet (low salt, low fat, low cholesterol)? Yes No No special diet prescribed Are you currently using tobacco? Yes No Are you exposed to second hand smoke? Yes No Are you drinking 6 to 8 glasses of water a day? (If allowed by your physician)? Yes No Not allowed by MD Current Weight How motivated are you to make changes in your health?Scale of 1 - 5 with 1 being least motivated and 5 being most 1 2 3 4 5 Does your current health condition stop you from doing things you enjoy? Yes No If yes, in what ways?Do you feel you should take an active role in your well being to ensure you are as healthy as you can be? Yes No If no, why not?Do you feel since you have a chronic health condition, that it is difficult to live a healthy life? Yes No If yes, why?What is your biggest fear with your health condition?*Would you like more educational information on your condition? Yes No If yes, please specify what you would be interested in learning.Please list all medications you are currently taking*Please include the medication name, dosage, how often you take the medication, and the condition you are treating. Be sure to include over the counter medications. What health goal would you like to achieve before our next contact?*** All medical information will be kept confidential in accordance with HIPAA. Thank you for taking the time to complete the questionnaire. We wish you continued success on your Road To Wellness!EmailThis field is for validation purposes and should be left unchanged. Δ
