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Health Survey

The goal of this survey is to help us understand your specific health and health care 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 through Optimal Phone Interpreters (OPI) 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).

Member Information

Health

WHAT IS YOUR HEIGHT WITHOUT SHOES?


















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

Nutrition

Fitness Level

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

Safety

Mood

Substance Use

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

Other Health Related Needs
























Thank you for taking the time to complete this assessment!