Complex Care Management Program

Comprehensive Health Risk Assessment

1 / Where do you currently live? (Select all that apply) /
  • House/Trailer/Apartment
  • Group home
  • Assisted living
  • Shelter
  • Transitional living
  • Homeless
  • Nursing home

2 / In the past 6 months, have you had concerns or fears of losing your home? /
  • Yes
  • No

3 / In the past 6 months, have you had problems with your home/living environment that might be affecting your health? (i.e. roaches, mold, lead, problems with a/c or heating)
If yes, please explain: /
  • Yes
  • No
Allow free text.
4 / Do you feel physically and emotionally safe with those that live with you? /
  • Yes
  • No
  • Not sure

5 / What is the highest level of education or grade completed? /
  • Elementary
  • Middle school
  • High school
  • College
  • Post-graduate

6 / What is your employment status? /
  • Employed
  • Unemployed
Allow free text.
7 / If unemployed:
What are your barriers to obtaining employment? /
  • Transportation
  • Finding or keeping a job
  • Job skills training
  • Interviewing skills
  • Appropriate clothing
  • Health status: (Specify)
Allow free text.
  • Not seeking employment

8 / Does your income provide enough to meet your basic needs like rent, utilities, clothing or medical co-pays?
If not, what basic needs do you have trouble meeting? /
  • Yes
  • No
Allow Free Text.
9 / In the past 6 months, have you had problems with a lapse in health insurance? /
  • Yes
  • No

10 / Do you sometimes have problems reading or understanding information about your health or medications? /
  • Yes
  • No

11 / Is there a language barrier that keeps you from communicating with your healthcare team? /
  • Yes
  • No

12 / In the past 6 months, have you missed any medical appointments because of family responsibilities such as caregiving or babysitting? /
  • Yes
  • No

13 / In the past 6 months, has it been hard to find family or friends that will help when you need medical assistance? /
  • Yes
  • No

14 / In the past 6 months, have you experienced any discrimination based on your sex, age, ethnicity, sexual orientation or health condition? /
  • Yes
  • No

15 / In the past 6 months, have you experienced any legal issues?
If yes and you feel comfortable sharing, what are those issues? /
  • Yes
  • No
Allow free text
16 / Are you currently facing any immigration issues?
If yes, please explain. /
  • Yes
  • No
Allow Free Text
17 / Are you currently receiving support from any other community agencies or working with any other case managers/social workers?
If so, what agencies and/or case managers? /
  • Yes
  • No
Allow free text.
18 / In the past 3 years:
[autogenerate from NextGen] /
  • PCP Kept appointments:
  • PCP No Shows:

19 / Do you do regular exercise/physical activity? /
  • Yes
  • No

20 / Have you seen any specialists in the last year?
If yes, which specialists? /
  • Yes
  • No
  • Cardiology
  • Endocrinologist
  • Gastroenterology
  • Nephrologist (Renal)
  • Neurology
  • Oncology/Hematology
  • Pulmonology

21 / Do you have any upcoming scheduled surgeries?
If yes:
  • Type:
  • Date:
Provider: /
  • Yes
  • No
Allow multiple entries.
22 / Have you gone to the ER for any of the following conditions in the past 12 months?
Heart Disease (Coronary Artery Disease, Congestive Heart Failure, Atrial Fibrillation) /
  • Yes
  • No
  • Not sure

23 / Lung Disease (Asthma, COPD, Emphysema) /
  • Yes
  • No
  • Not sure

24 / Liver Disease, such as Hepatitis or Cirrhosis /
  • Yes
  • No
  • Not sure

25 / Diabetes /
  • Yes
  • No
  • Not sure

26 / Cancer /
  • Yes
  • No
  • Not sure

27 / Chronic Kidney Disease /
  • Yes
  • No
  • Not sure

28 / Depression /
  • Yes
  • No
  • Not sure

29 / Hypertension /
  • Yes
  • No
  • Not sure

30 / Chronic Mental Health Condition (Bipolar, Schizophrenia) /
  • Yes
  • No
  • Not sure

31 / List current medications, including OTC (from EMR):
Please have patient explain the type, dose, frequency, & purpose of each medication he/she is taking. Is the patient able to correctly explain this? /
  • Yes
  • No

32 / Please, check all the potential medication issues you may have: /
  • I sometimes forget to take my medications.
  • I sometimes forget to get refills before I run out.
  • When I feel better, I sometimes stop taking my medicine as instructed.
  • I sometimes feel worse when I take my medicine, and so I stop taking it.
  • No transportation or access to pharmacy.
  • No insurance coverage for meds.
  • Cannot afford.
  • Cannot read labels.
  • I do not know and understand the long-term benefit of taking my medicine as instructed.

33 / Do you use tobacco products? /
  • Yes
  • No

34 / Do you have medical supplies that you use on a daily basis?
If so, are you having any difficulty obtaining those supplies? /
  • Yes
  • No
If yes, what are they?
Allow free text
  • Yes
  • No

35 / Do you need help with activities of daily living (i.e. bathing, dressing yourself, cleaning your house, cooking, etc)?
If Yes:
What activities do you need help with?
Do you have adequate help with this? /
  • Yes
  • No
Allow free text.
  • Yes
  • No

36 / Do you have any problems with your memory that make it difficult to maintain your health?
If yes, please explain: /
  • Yes
  • No
Allow Free Text
37 / How often do you have difficulty falling asleep, staying asleep, or feeling tired in the morning? /
  • Never or less than once weekly
  • 1-2 times per week
  • 3-4 times per week
  • 5 or more times per week

38 / Has there been an unintentional loss of 10 or more pounds in the last six months? /
  • Yes
  • No
  • Not sure

39 / If the member is over 65 years of age, ask:
Have you fallen in the last 6 months?
If yes, why do you think you fell? /
  • Yes
  • No
  • Not sure
  • Fall or trip outside home
  • Home hazards such as slippery floors or scattered rugs
  • Impaired mobility (walks with assisted device, such as walker, cane)
  • Insomnia
  • Dizziness
  • Vision problems
  • Medication problems
  • Muscle weakness
  • Pets
  • Uneven surfaces
  • Stairs
  • Slipped due to weather conditions (ice, rain, etc.)
  • Recent surgery or medical procedures (hip or knee injuries)
  • Bladder control problems
  • Other ______

40 / CAGE:
Have you ever felt you should cut down on your drinking or drug use? /
  • Yes
  • No

41 / Have people annoyed you by criticizing your drinking or drug use? /
  • Yes
  • No

42 / Have you ever felt bad or guilty about your drinking or drug use? /
  • Yes
  • No

43 / Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (“eye opener”)? /
  • Yes
  • No

44 / In the past 28 days, on how many days did you have 4 or more (females) or 5 or more (males) drinks? / #:
45 / In the past 28 days, how many days have you used drugs?
Indicate which of the following: / #:
  • Marijuana
  • Inhalants
  • Amphetamines/stimulants
  • Cocaine
  • Hallucinogens
  • Sedatives
  • Opioids

46 / Do you attend AA? /
  • Yes
  • No

47 / Do you attend NA? /
  • Yes
  • No

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