Health Assessment General Health Assessment Form Please complete this Health Assessment to help us determine if you could benefit from any of our Health & Wellness Programs (Diabetes in Control, Asthma Matters, Healthy Living, Healthy Heart, and Healthy Mind). After reviewing your completed form, a Community First Health Educator will reach out to you. Step 1 of 9 - General Information 11% Name* First Last Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Date of Birth (MM/DD/YYYY)* Date Format: MM slash DD slash YYYY Member ID (Located on your Community First Member ID card - Example: A0101000001)*Height*Feet*InchesWeight*How should we contact you?* Email Phone Clinical HistoryDo you have any of the following health conditions? Arthritis Asthma Chronic Obstructive Pulmonary Disease (COPD)/Emphysema Coronary Artery Disease (CAD) Diabetes Heart Failure Hypertension (High Blood Pressure) Weight-related condition (overweight, obesity or underweight) None I don't know/I'm not sure Risk FactorsDo you have any of the following risk factors for a chronic condition?* Borderline high blood pressure Borderline high blood sugar (prediabetes) Excessive alcohol consumption Exposure to toxins/chemicals/pollution High cholesterol or lipids (dyslipidemia) History of sun exposure Obesity Sedentary lifestyle Smoking Substance use/addiction Other None I don't know/I'm not sure MedicationDo you take any prescription, over-the-counter, or herbal/supplement medications?* Yes No Preventive Care - VaccinationsHave you had any of the following vaccinations? Check all that apply.* Hepatitis A Hepatitis B HPV Influenza (within the last year) Measles, Mumps, Rubella (MMP) Meningococcal Pneumococcal (within the last 5 years) Tdap (or booster within the last 10 years) Varicella Zoster Other None I don't know/I'm not sure Social Determinants of HealthDo you have difficulties meeting your basic daily and/or health care needs related to problems accessing community resources? (i.e., free or low-cost health care, parenting resources, etc.) Yes No I don't know/I'm not sure In the past six months, have you had difficulty buying food, paying bills, meeting basic needs, and/or paying for the medical needs of you and/or your family? Yes No I don't know/I'm not sure Self-ManagementAre you currently being treated for any medical conditions or illnesses? Yes No Do you understand your current treatment plan? Yes No I don't know/I'm not sure N/A Do you have any current concerns or questions regarding your condition(s)? Yes No I don't know/I'm not sure N/A Do you understand the importance of managing your health and monitoring condition(s) to reduce your risk of complications? Yes No I don't know/I'm not sure Asthma Assessment QuestionsIf you have been diagnosed with asthma, please answer the following questions. If not, click "Next" to skip these questions.When were you diagnosed with asthma? Less than one year ago 1-5 years ago 6-10 years ago Over 10 years ago In your opinion, your asthma is Mild Moderate Severe Do you have a prescription to help control your asthma? Rescue medication (used as needed) Daily use medication No prescription Diabetes Assessment QuestionsIf you have been diagnosed with diabetes, please answer the following questions. If not, click "Next" to skip these questions. When were you diagnosed with diabetes? Less than one year ago 1-5 years ago 6-10 years ago Over 10 years ago What is your diagnosis? Pre-diabetic Type 1 diabetic (severe risk) Type 2 diabetic (moderate risk) I don't know/I'm not sure In your opinion, is your diabetes under control? Yes No High Blood Pressure Assessment QuestionsIf you have been diagnosed with high blood pressure, please answer the following questions. If not, click "Next" to skip these questions.When were you diagnosed with high blood pressure? Less than one year ago 1-5 years ago 6-10 years ago Over 10 years ago In your opinion, is your high blood pressure under control? Yes No Do you have a prescription? Yes No Lifestyle Assessment QuestionsDo you feel like you get enough exercise? Yes No Do you follow a regular exercise routine? Yes No What type of exercise do you enjoy? (i.e., walking, bike riding, swimming)Are you concerned about your weight? Yes No Do you feel your weight holds you back from daily activities? Yes No Mental Health Assessment QuestionsOver the past two weeks, how often have you been bothered by feeling down, depressed, or hopeless? Not at all Several days More than half of the days Nearly every day Over the past two weeks, how often have you had little interest or pleasure in doing things? Not at all Several days More than half of the days Nearly every day If you feel you need to speak with someone about your mental health, please contact your PCP and/or behavioral health provider or reach out to one of the organizations listed below. 24-hour Crisis Line: 800-316-9241 or 210-223-SAFE (7233) SAPD Public Safety Unit: 210-207-7273 Bexar County Sheriff: 210-335-6000 Poison Control: 800-222-1222 Members can also call 2-1-1 or visit 211texas.org to locate a Behavioral Health (BH) professional. Questions? We’re here to help. Email firstname.lastname@example.org or call (210) 358-6055 for more information.