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:
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*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