"Health Risk Assessment Form - Coventry Health Care of Florida" - Florida

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Download "Health Risk Assessment Form - Coventry Health Care of Florida" - Florida

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In order for the health plan to help you with all of your health care needs, please fill out the Health Risk Assessment (HRA) form and return it to us.
Thank you.
H E A L T H R I S K A S S E S S M E N T F O R M
Date: ________________
Member Name: ________________________________ Member I.D.#: _________________ DOB: _________________
Address: _____________________________________ City/State: ____________________ Zip: ___________________
Home Phone #: ________________________________ Cell #: _______________________ Other #: ________________
Primary Care Physician: ______________________________________________________________________________
Previous Primary Care Physician: _____________________________________ Phone #: _________________________
Other Insurance: ____________________________________________________________________________________
Are you currently enrolled in any state program (for dual enrollment purposes)?
____ YES
____ NO
Are you receiving WIC services?
____ YES
____ NO
Are immunizations up to date?
____ YES
____ NO
Are you taking any medications?
____ YES
____ NO
If yes, list medicines: 1. _________________ 2. __________________ 3. __________________ 4. _________________
Are you using any medical equipment, such as glucometer, nebulizer, wheelchair, hospital bed?
____ YES
____ NO
If yes, explain: ______________________________________________________________________________________
Are you being treated for any of the medical conditions listed?
YES
NO
YES
NO
Asthma
____
____
Lung Disorder
____
____
Cancer
____
____
Liver Disorder
____
____
Heart Problems
____
____
Sickle Cell
____
____
High Blood Pressure
____
____
Kidney Disorder
____
____
Diabetes
____
____
Are you pregnant now?
____
____
Your expected delivery date: ________________________
Are you receiving services from the Florida Healthy Start Program?
____ YES
____ NO
Have you had a baby within the past 8 weeks?
____ YES
____ NO
Date: ________
Have you received services in an Emergency Room recently?
____ YES
____ NO
If yes, explain: ______________________________________________________________________________________
Have you been hospitalized in the past year?
____ YES
____ NO
If yes, explain: ______________________________________________________________________________________
Have you undergone any surgical procedures?
____ YES
____ NO
If yes, explain: ______________________________________________________________________________________
Would you like to receive information on family planning or pregnancy prevention?
____ YES
____ NO
Would you like to receive information on Teen Abstinence Program?
____ YES
____ NO
vsf md 5-5/14
vv md 92-5/14
Item #
CHVSF_559
In order for the health plan to help you with all of your health care needs, please fill out the Health Risk Assessment (HRA) form and return it to us.
Thank you.
H E A L T H R I S K A S S E S S M E N T F O R M
Date: ________________
Member Name: ________________________________ Member I.D.#: _________________ DOB: _________________
Address: _____________________________________ City/State: ____________________ Zip: ___________________
Home Phone #: ________________________________ Cell #: _______________________ Other #: ________________
Primary Care Physician: ______________________________________________________________________________
Previous Primary Care Physician: _____________________________________ Phone #: _________________________
Other Insurance: ____________________________________________________________________________________
Are you currently enrolled in any state program (for dual enrollment purposes)?
____ YES
____ NO
Are you receiving WIC services?
____ YES
____ NO
Are immunizations up to date?
____ YES
____ NO
Are you taking any medications?
____ YES
____ NO
If yes, list medicines: 1. _________________ 2. __________________ 3. __________________ 4. _________________
Are you using any medical equipment, such as glucometer, nebulizer, wheelchair, hospital bed?
____ YES
____ NO
If yes, explain: ______________________________________________________________________________________
Are you being treated for any of the medical conditions listed?
YES
NO
YES
NO
Asthma
____
____
Lung Disorder
____
____
Cancer
____
____
Liver Disorder
____
____
Heart Problems
____
____
Sickle Cell
____
____
High Blood Pressure
____
____
Kidney Disorder
____
____
Diabetes
____
____
Are you pregnant now?
____
____
Your expected delivery date: ________________________
Are you receiving services from the Florida Healthy Start Program?
____ YES
____ NO
Have you had a baby within the past 8 weeks?
____ YES
____ NO
Date: ________
Have you received services in an Emergency Room recently?
____ YES
____ NO
If yes, explain: ______________________________________________________________________________________
Have you been hospitalized in the past year?
____ YES
____ NO
If yes, explain: ______________________________________________________________________________________
Have you undergone any surgical procedures?
____ YES
____ NO
If yes, explain: ______________________________________________________________________________________
Would you like to receive information on family planning or pregnancy prevention?
____ YES
____ NO
Would you like to receive information on Teen Abstinence Program?
____ YES
____ NO
vsf md 5-5/14
vv md 92-5/14
Item #
CHVSF_559