Submit Form - HA 27 EN

Health Appraisal Survey

Member ID# *

Please provide a valid Member ID#.

Name *

Please provide a valid Name.

Address *

Please provide a valid Address.

Dear Aspire member,

Welcome to Aspire Health Plan. So that we may help you achieve your full health potential, we ask all new members on the plan to complete a health appraisal survey. Please take a few minutes to complete the survey and return it in the postage-paid envelope. You are not required to provide this information and your responses will not affect your membership. Your health information is confidential and will be used by your personal health representative to offer programs and services tailored to supporting your health journey.

Age *

Please provide a valid Age.

In general, would you say your health is *

Excellent

Good

Fair

Very Good

Poor

Please choose one option for In general, would you say your health is.

Do you have a lot of difficulty climbing up 10 steps or walking a quarter mile? *

No

Yes

Please choose one option for Do you have a lot of difficulty climbing up 10 steps or walking a quarter mile?.

Have you fallen or had problems with balance in the past six months? *

No

Yes

Please choose one option for Have you fallen or had problems with balance in the past six months?.

Do you have any of the following conditions?

No

Yes

Please choose one option for Do you have any of the following conditions?.

Heart disease

Please provide a valid Heart disease.

Diabetes

Please provide a valid Diabetes.

High blood pressure

Please provide a valid High blood pressure.

High cholesterol

Please provide a valid High cholesterol.

Lung disease, COPD, or breathing problems

Please provide a valid Lung disease, COPD, or breathing problems.

Heart failure

Please provide a valid Heart failure.

Cancer type

Please provide a valid Cancer type.

Cancer type

Please provide a valid Cancer type.

Neurological disorders ( such as stroke, epilepsy, Alzheimer's, dementia, multiple sclerosis, Parkinson's)

Please provide a valid Neurological disorders ( such as stroke, epilepsy, Alzheimer's, dementia, multiple sclerosis, Parkinson's).

Neurological disorders type

Please provide a valid Neurological disorders type.

How many prescription medications do you take from all your doctors? *

Seven or fewer

Eight or more

Please choose one option for How many prescription medications do you take from all your doctors?.

Have you had an unplanned hospitalization in the past 6 months? *

Yes

No

Please choose one option for Have you had an unplanned hospitalization in the past 6 months?.

Have you been to the emergency room in the past 6 months? *

No

Yes

Please choose one option for Have you been to the emergency room in the past 6 months?.

Many people experience leakage of urine also called urinary incontinence. In the past six months, have you experienced occasional leaking of urine? *

No

Yes

Please choose one option for Many people experience leakage of urine also called urinary incontinence. In the past six months, have you experienced occasional leaking of urine?.

If yes, we encourage you to speak with your physician about the treatment options available.

Do you have a health condition or an urgent need you want us to be aware of? *

Yes

No

Please choose one option for Do you have a health condition or an urgent need you want us to be aware of?.

If yes, please describe

Please provide a valid If yes, please describe.

In the past two weeks have you felt down, depressed or hopeless? *

Yes

No

Please choose one option for In the past two weeks have you felt down, depressed or hopeless?.

In the past two weeks have you had little interest or pleasure in doing things you normally like to do? *

No

Yes

Please choose one option for In the past two weeks have you had little interest or pleasure in doing things you normally like to do?.

In the past two weeks have you experienced uncomfortable feelings of being on edge, nervousness or anxiety? *

No

Yes

Please choose one option for In the past two weeks have you experienced uncomfortable feelings of being on edge, nervousness or anxiety?.

In the past 12 months have you ran out of food or worried that you would run out of food because you didn't have money to buy more. *

No

Yes

Please choose one option for In the past 12 months have you ran out of food or worried that you would run out of food because you didn't have money to buy more..

Was there a time in the last six months that you were unable to a ord your medications?

No

Yes

Please choose one option for Was there a time in the last six months that you were unable to a ord your medications?.

Since joining the health plan have you scheduled an appointment with your assigned primary care physician (family practice or internal medicine physician)? *

No

Yes

Please choose one option for Since joining the health plan have you scheduled an appointment with your assigned primary care physician (family practice or internal medicine physician)?.

If yes, when is your appointment?

Please provide a valid If yes, when is your appointment?.

We encourage you to schedule an Annual Wellness Visit with your Primary Care Physician, which is a covered preventative care benefit.

In the past year have you or any family members you live with been unable to get food when it was really needed? *

No

Yes

I choose to not answer this question

Please choose one option for In the past year have you or any family members you live with been unable to get food when it was really needed?.

Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? Check all that apply. *

Yes, it has kept me from medical appointments

Yes, it has kept me from getting my medications, going

No

I choose to not answer this question

Please choose one option for Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? Check all that apply..

What is your housing situation today? *

I have housing

I do not have housing ( staying with others, in a hotel,

I choose to not answer this question

Please choose one option for What is your housing situation today?.

Are you worried about losing your housing? *

Yes

No

I choose to not answer this question

Please choose one option for Are you worried about losing your housing?.

Do you have access to the internet and a laptop or mobile device (such as a smart phone or tablet) at home? *

No

Yes

Please choose one option for Do you have access to the internet and a laptop or mobile device (such as a smart phone or tablet) at home?.

Have you ever participated in a video visit with your doctor? *

No

Yes

Please choose one option for Have you ever participated in a video visit with your doctor?.

Would you be interested in learning how to participate in $0 video visits with your doctor? *

No

Yes

Please choose one option for Would you be interested in learning how to participate in $0 video visits with your doctor?.

Thank you for taking the time to complete this survey. Our goal is to assist you and your doctor in taking full advantage of programs and services provided through Aspire Health Plan, to improve your health and our healthcare delivery.

You may be contacted in the next few weeks to follow-up on any items identified during this survey that could be beneficial to your health.

If you would like to speak with someone at Aspire Health Plan, please call us toll free at ( 855) 570-1600, or TTY 711. We would be happy to assist you.

H8764_ MBR_ HealthSurvey_ 0824_ C