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: Invalid ID

*First Name:

*Last Name:

*Phone Number:

*Date of Birth: month 1 2 3 4 5 6 7 8 9 10 11 12 /  day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 /  year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 1899 1898 1897 1896 1895 1894 1893 1892 1891 1890 1889 1888 1887 1886 1885            Select a month.     Select a day.     Select a year.

*Gender: Male Female

Questions

1. When was the last time you went to a doctor? Within the last six months Within the last year Within the last two years Greater than two years

2. Do you have diabetes, asthma, blood pressure issues or heart disease? Yes No

3. How many times have you been admitted to the hospital or have been seen in the emergency room within the last 2 years? Zero 1 – 3 times 4 – 6 times 7 times or more

4. If you were admitted to the hospital or seen in the emergency room, what was the reason? Diabetes Asthma Blood Pressure or Heart Disease Other

5. Do you have any concerns or questions about your medications? Yes No

6. Do you think you are suffering from depression (persistent feeling of sadness and loss of interest), anxiety (worry about the unknown) or stress? Yes No

7. Considering your age, how would you describe your overall health? Excellent Good Fair Poor

8. Do you usually have a ride to the doctor or to get your medications? Yes No

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? Food Transportation Health Insurance Rent/House Payment Electricity Medicine Clothing Phone (Home or Cell) Water Medical Care Childcare Other

10. Have you or a family member been a traveling farmworker in the past two years? Yes No