|
|
Producer Information
|
|
|
|
|
|
|
|
Personal Information
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
*By providing a telephone number and/or an email address, I hereby authorize Capital Blue Cross, its affiliates,
subsidiaries and/or agents (collectively "Capital Blue Cross") to communicate with me by phone, text
messages, faxes, and/or emails for billing, transactional, informational, marketing, or any other purposes
including, without limitation, calls or messages made or sent using an automatic telephone dialing system or
artificial/prerecorded voice. I understand that I may opt out at any time.
|
| |
Health risk questionnaire
|
| |
| 1. In general, how do you rate your overall health? |
|
| |
| 2. Do you have any of the following conditions? |
| Cancer |
|
| Coronary artery disease (CAD) |
|
Breathing problems like chronic obstructive,
pulmonary disease (COPD) or Asthma |
|
| Diabetes |
|
| Heart failure |
|
| High blood pressure (HTN) |
|
| Depression |
|
| Anxiety disorder |
|
| Substance use disorder |
|
| Pain interfering with activity |
|
| Take six or more medications daily |
|
| |
| 3. Do you have someone to assist with healthcare decisions? |
|
|
| |
| 4. In the last 12 months, have you been to the emergency room or urgent care center three or more times? |
|
|
| |
| 5. Do you have a primary care physician (PCP)? |
|
|
|
|
| |
| 6. Have you had a fall within the last 12 months? |
|
|
| |
| 7. Do you have difficulty with the following? |
| Bathing |
|
| Walking/balance |
|
| Eating |
|
| Using the bathroom |
|
| Getting dressed |
|
Reading fine print/seeing
distance/blurry vision |
|
| Hearing |
|
| Concentration |
|
| Remembering |
|
| Making decisions |
|
| Financial strain |
|
| Medication costs |
|
| |
| 8. In the last two weeks, how often have you been bothered by feeling down or having little interest or pleasure in doing things? |
|
|
| |
| 9. What is your housing situation today? |
|
|
| |
| 10. Think about the place you live. Do you have problems with any of the following? (Check all that apply.) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| |
| 11. Within the past 12 months, you worried that your food would run out before you got money to buy more? |
|
|
| |
| 12. Within the past 12 months, the food you bought just didn't last and you didn't have money to get more? |
|
|
| |
| 13. In the past 12 months, has lack of transportation kept you from your medical appointments,
meetings, work, or from getting things needed for daily living? |
|
|
| |
| 14. Which of the following best describes your race or ethic group? |
|
|
|
|
|
|
|
|
|
|
|
|
| |
| 15. Do you use applications/programs (such as Zoom) on your cell phone, computer, or another electronic device (without asking for help from someone else)? |
|
|
| |
| 16. Can you set up video chat using your cell phone, computer, or another electronic device (without asking for help from someone else)? |
|
|
| |
| 17. Can you solve or figure out how to solve basic technical issues when using your cell phone, computer, or another electronic device (without asking for help from someone else)? |
|
|
