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HEALTH SURVEY

The goal of this survey is to help us understand your health and specific healthcare needs so we can work together to help provide you with the services to reach your health goal(s).

The information submitted in this survey will be used internally by our Care Management Department and may be shared with your Primary Care Physician (PCP) 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.

Member Information

Distance in Miles

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
























IMPORTANT NOTE: If you do not check the box above, it will be indicated that you do want to participate in the GlobalHealth Care Management Program.

 

Thank you for taking the time to complete this Health Survey!