First name
Last name
Member ID number
Date of birth
I do not wish to complete this survey.
1. In general, would you say your health is:
Excellent
Very good
Good
Fair
Poor
2. In the past 12 months, have you stayed overnight as a patient in a hospital?
Not at all
One time
Two to three times
More than three times
3. In the past 12 months, how many times did you visit a physician or clinic?
Not at all
One time
Two to three times
Four to six times
More than six times
4. Is there a friend, relative or neighbor who can take care of you for a few days if necessary?
Yes
No
5. How often are you in contact with people you care about through phone calls with family and friends, virtual visits or church or community meetings?
Less than once a week
1-2 times a week
3-5 times a week
More than 5 times a week
6. Please check all conditions for which you are
currently
receiving medical treatment. If none of the conditions apply to you, select None.
Ankle or leg swelling
Arthritis
Breathing problems
Cancer
Heart problems
High blood pressure
Mental health problems
Urinary problems
Diabetes
None
7. How many different prescription medicines do you take?
8. How is your eyesight?
Excellent
Good
Fair
Poor
None
This means your eyesight while wearing glasses or contacts, if you use them.
9. Have you had a fall or problem with balance in the last 12 months?
Yes
No
Don't know
10. Do you live:
Alone
With spouse
With a son or daughter
Other
Please explain relationship (e.g., friend):
11. Do you live in:
An independent house, apartment, condominium or mobile home
An assisted-living apartment or board and care home
A nursing home
Other
Please explain (or provide name of facility):
12. Please select one for each of these:
Able to do this without help
Need some help
Cannot do this at all without help
Bathing
Dressing
Eating
Toileting
Walking
Taking medicines
Meal preparation
Housekeeping chores
Shopping and errands
Transportation
Money management
13. How difficult is it for you to afford to pay for the following:
Very difficult
Somewhat difficult
Not difficult at all
Food/groceries
Rent/mortgage
Medical bills
Utilities/electric bill
Phone bill
14. Are you receiving Medicaid or financial Medical Assistance?
Yes
No
Don't know
15. Do you put off going to the doctor because of distance or transportation needs?
Yes
No
Don't know
16. In the past six months, have you lost more than 10 pounds without trying?
Yes
No
Don't know
17. Do you often feel sad or blue?
Yes
No
18. Are you?
Male
Female
Please type your full name below to electronically sign your assessment. If you have had someone complete this form for you, please have them type their name and phone number below.
Signature
Phone number