Annual Health Appraisal

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HEALTH SURVEY

The goal of this survey is to help us understand your specific health and healthcare needs. This assists in us working together to get you the services you need in order to reach your health goal(s).

The information submitted in this survey will only be used internally by our Care Management Department and may be shared with your Primary Care Physician if there are gaps in care that need to be addressed.

Any information provided will not be used against you in any way or impact the services you obtain from the health plan.

Completion and submission of the confidential Health Survey implies consent to its stated use; however, you do have the option to decline completion of this survey.

Translation Services: GlobalHealth offers interpretation services for our members 24 hours a day, 7 days a week, 365 days per year. Professional Certified Medical Interpreters allow our members to enjoy culturally sensitive translation services when speaking to our health plan staff. Call Customer Care at (877) 280-5600 (TTY:711).

General Health

In general, how would you rate your health?

Excellent
Very Good
Good
Fair
Poor

Physical Activity

In the past 7 days, how many days did you exercise?

On the days when you exercised, how long did you exercise? Minutes per day

How intense was your typical exercise?

Light (stretching or slow walking)
Moderate (brisk walking)
Heavy (jogging or swimming)
Very Heavy (running or stair climbing)
I am currently not exercising

Nutrition

In the past 7 days, how many servings of fruits and vegetables did you typically eat each day? (1 serving = 1 cup of fresh vegetables, 1/2 cup of cooked vegetables or 1 medium piece of fruit. 1 cup = size of a baseball.) Servings per day

In the past 7 days, how many servings of high fiber or whole grain foods did you typically eat each day? (1 serving = 1 slice of 100% whole wheat bread, 1 cup of whole-grain or high-fiber ready-to-eat cereal, 1/2 cup of cooked cereal such as oatmeal, or 1/2 cup of cooked brown rice or whole wheat pasta.) Enter servings per day

In the past 7 days, how many servings of fried or high-fat foods did you typically eat each day? (Examples include fried chicken, fried fish, bacon, French fries, potato chips, corn chips, doughnuts, creamy salad dressings, or foods made with whole milk, cream, cheese or mayonnaise.) Enter servings per day

In the past 7 days, how many sugar-sweetened (not diet) beverages did you typically consume each day? Enter servings per day

Preventive Services / Screenings

When did you last receive the following preventive services or screenings?

Blood Pressure

Cholesterol

Flu Vaccine

Pneumonia Vaccine

Routine Physical

Routine Eye Exam

Colorectal Cancer Screening

Bone Mineral Density (BMD) Test

Hemoglobin A1c

Medication Review

Please list all over-the-counter and prescription medications you are taking.

Drug 1

Depression

During the past 30 days, have you often been bothered feeling little interest or pleasure in doing things?

Yes
No

During the past 30 days, have you often been bothered by feeling down, depressed or hopeless?

Yes
No

Stress

How often is stress a problem for you in handling such things as your health, finances, family or social relationship, work, etc.?

Never or rarely
Sometimes
Often
Always

Support

Do you have a caregiver?

Yes
No, I do not need assistance
No, but I need one

Thank you for taking the time to complete this assessment!