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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).

Member Information

Enter distance in miles

General Health

Physical Activity
Minutes per day

Substance Use

Servings per day
Enter servings per day
Enter servings per day
Enter servings per day
Self-Reported Measures

Preventive Services / Screenings

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

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




Thank you for taking the time to complete this assessment!