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Health Appraisal Form

  1. Age*

  2. Sex/Gender*

  3. Are you of Hispanic, Latino, or of Spanish origin?*

  4. How would you describe yourself? (Race)*

  5. Is English your primary language?*

  6. Do you need interpreter services such as TTY or Language Line?*

  7. Do you have a vision impairment that requires special reading materials such as large print materials or Braille?*

  8. Do you have a hearing impairment that requires special equipment other than hearing aids?*

  9. What is your marital status?*

  10. What is your highest level of education?*

  11. What is your level of income?*

  12. Have you seen your primary care provider (PCP) for a wellness, preventive, or well child visit?*

  13. Have you seen a dentist for a wellness/preventive visit in the past year?*

  14. Have you been treated in the Emergency Room (ER) in the past year?*

  15. Have you been admitted to a hospital in the past year?*

  16. Do you have medical conditions that require regular medical care (clinic visits) and/or prescription medication?*

  17. Do you have any of the following conditions:*

    Check all that apply.

  18. In general, would you say your health is:*

  19. How much bodily pain have you had during the past 4 weeks?*

  20. How much physical activity do you get per day?*

  21. Does your health keep you from working at a job, doing work around the house, or going to school?*

  22. Have you been unable to do certain kinds or amounts of work, housework, or schoolwork because of your health?*

  23. For how long (if at all) has your health limited you in each of the following activities?

  24. The kinds or amounts of vigorous activities you can do, like lifting heavy objects, running or participating in strenuous sports.*

  25. The kinds or amounts of moderate activities you can do, like moving a table, carrying groceries, or bowling.*

  26. Walking uphill or climbing a few flights of stairs.*

  27. Bending, lifting, or stooping.*

  28. Walking one block.*

  29. Eating, dressing, bathing, or using the toilet.*

  30. For each of the following questions, please select the one answer that comes closest to the way you have been feeling during the past month.

  31. How much of the time, during the past month, has your health limited your social activities (like visiting with friends or close relatives)?*

  32. How much of the time, during the past month, have you been a very nervous person?

  33. During the past month, how much of the time have you felt calm and peaceful?*

  34. How much of the time , during the past month, have you felt downhearted and blue?*

  35. During the past month, how much of the time have you been a happy person?*

  36. How often, during the past month, have you felt so down in the dumps that nothing could cheer you up?*

  37. Do you have any Mental Health conditions?*

  38. Do you have a physical or developmental delay?*

  39. Have you been diagnosed with Serious and Persistent Mental Illness (SPMI)?*

  40. Do you feel socially isolated?*

  41. Do you feel safe in your home?*

  42. Do you have Chemical Dependency (alcohol, and/or illegal or prescription drugs)?*

  43. Do you smoke cigarettes, use smokeless tobacco, or vape?*

  44. Do you need help getting transportation to dental and/or medical appointments?*

  45. What is your current housing situation?*

  46. Do you have any environmental concerns in your current housing situation?*

  47. Do you have access to the internet?*

  48. Do you use the internet?*

  49. Do you work outside the home?*

  50. Do you use a seat belt?*

  51. Please choose preventive screenings completed within the last year:*

  52. Are there any other health concerns you would like to mention?*

  53. Relationship to member*

  54. Leave This Blank:

  55. This field is not part of the form submission.