Annual Health Appraisal

Member Information

Last Name *

First Name *

Member ID *

Date of Birth *

Age

Gender

Email

Primary Care Physician

Have you received your Insurance ID Card this year?

What is your marital status?

Do you have children?

If yes, how many?

Language spoken in the home:

If other than English, do you prefer to receive GHI communication in this language?

What race and ethnicity do you identify with?

Ethnicity:

What is your level of education?

Does your income level keep you from getting the healthcare you need?

If yes, what is your income level?

Health

In general, how would you rate your health?

How would you describe the condition of your mouth and teeth (including dentures)?

How many hours of sleep do you usually get each night?

Do you snore or has anyone told you that you snore?

In the past 7 days, how often have you felt sleepy during the daytime?

If your blood pressure was checked within the past year, what was it when it was last checked?

If your cholesterol was checked within the past year, what was your total cholesterol when it was last checked?

If your glucose was checked, what was your fasting blood glucose (blood sugar) level the last time it was checked?

If diabetic, and if you had your hemoglobin A1c level checked in the past year, what was the level?

WHAT IS YOUR HEIGHT WITHOUT SHOES?

Feet

Inches

What is your weight without shoes? (lbs)

Do you take aspirin daily, if prescribed?

Is the Policy Holder still employed?

Have you missed any workdays in the past 30 days due to personal or family health issues?

In the past 12 months, how many times have you visited a doctor or clinic?

How many times have you been to the emergency room in the past year?

Have you been hospitalized in the past 6 months?

Do you have surgery planned in the next 3 months?

Have you ever been treated for the following (check all that apply)?

Asthma
Respiratory Disease
Difficulty Breathing
Mental Disorder
Metabolic Syndrome/Pre-Diabetes/Diabetes
COPD
Renal Disorder
HIV/AIDS
Endrocrine Disorder
Cardiac Disease
Cancer
Stomach or Intestinal Disorder
Neurological Disorder
Auto-Immune Disease
Emphysema
Urological Disorder
Substance Abuse Disorder

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 (fecal occult blood test, flexible sigmoidoscopy, or colonoscopy)

Pap Smear (females only)

Mammogram (females only)

Neuropathy (Diabetics only)

Bone Mineral Density (BMD) Test

Hemoglobin A1c

Medication Review

Nutrition

In the past 7 days, how many servings of fruit 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)

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 wholegrain or high-fiber ready-to-eat cereal, ½ cup of cooked cereal such as oatmeal, or ½ cup of cooked brown rice or whole wheat pasta)

In the past 7 days, how many servings of fried or high-fat foods did you typically eat each day? (fried chicken/fish/bacon, French fries, potato chips, corn chips, dough nuts, creamy salad dressing, and foods made w/whole milk, cream, cheese, or mayonnaise

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

Fitness Level

HOW OFTEN DO YOU EXERCISE OR PARTICIPATE IN PHYSICAL ACTIVITY, AND FOR HOW LONG?

Days per week

Minutes per day

How intense is your typical exercise

In the past 7 days, how much pain have you felt?

In the past 7 days, did you need help from others for eating, getting dressed, grooming, bathing, walking, or using the toilet?

In the past 7 days, did you need help from others with laundry, housekeeping, banking, shopping, using the telephone, food preparation, transportation, or preparing or taking your own medications?

Safety

Do you always fasten your seat belt when you are in a car?

Do you always lock your doors and windows where you live?

In the past 12 months, how many sexual partners have you had?

Do you and your partner use any protection against STDs?

Mood

Little interest or pleasure in doing things?

Feeling down, depressed or hopeless?

Feeling nervous, anxious, or on edge?

Not being able to stop or control worrying?

How often do you get the social and emotional support you need?

Substance Use

In the past year, how often have you used the following?

Alcohol - Men (5 or more drinks per day) or Women (4 or more drinks per day)

Tobacco/Nicotine Products

Prescription Drugs for Non-Medical Reasons

Illegal Drugs

Other Health Related Needs

Do you have any vision needs?

Need an exam
Need glasses/contacts
Glaucoma
Cataracts

Do you have any hearing needs?

Need an exam
Need hearing aides
TTY/Amplified phone
Assistive devices for the home

Do you have a Caregiver?

If you answered yes above are they able to meet your needs?

Do you have any need for the following community resources?

Utility/Rent Payments
Prescription Drug Assistance
Eyeglasses/Contacts Assistance
Hearing Aide Assistance
Medical Equipment Assistance
Food Bank
Other

Are any of the following keeping you from getting the services you need for your health?

Language, reading or writing restrictions
Lack of reliable transportation
Limited understanding of health conditions
Lack of motivation
Financial or insurance issues
Cultural or spiritual beliefs
Visual or hearing impairment
Psychological impairment

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