WELCOME TO COMMUNITY!   (haga clic aquí para la versión en español)
We are happy to have you as our Member. Community is dedicated to providing you great health care. We also want to help you take charge of your own health! Please take our Health Risk Assessment. We will keep your answers private and only use them to improve the care that we give you. Fill out the survey and submit. We will review it and contact you if we see any potential issues. In addition, share your results with your doctor.

Thank you for helping Community serve you better!

*Member ID:  
*First Name:  
*Last Name:  
*Phone Number:  
*Date of Birth:


1. When was the last time you went to a doctor?

2. Do you have diabetes, asthma, blood pressure issues or heart disease?

3. How many times have you been admitted to the hospital or have been seen in the emergency room within the last 2 years?

4. If you were admitted to the hospital or seen in the emergency room, what was the reason?

5. Do you have any concerns or questions about your medications?

6. Do you think you are suffering from depression (persistent feeling of sadness and loss of interest), anxiety (worry about the unknown) or stress?

7. Considering your age, how would you describe your overall health?

8. Do you usually have a ride to the doctor or to get your medications?

9. In the past year, have you or your family members that live with you been unable to get any of the following when you needed them? Check all that apply?

10. Have you or a family member been a traveling farmworker in the past two years?