Health Assessment Please complete this online Health Assessment to help us better serve your health needs. If you have any questions, please reach out to a Community First Health Educator at healthyhelp@cfhp.com. Step 1 of 3 - General Information 33% Member ID (Located on your Community First Member ID card - Example: A0101000001)* Name* First Last Phone*Email* Date (MM/DD/YYYY)* MM slash DD slash YYYY Height* FeetInches* InchesWeight* Body Mass Index (BMI)* Calculate your BMI HERE General Care Initial AssessmentHow would you rate your overall health? Excellent Good Fair Poor Very Poor What is your preferred language? English Spanish French German Arabic Hebrew Japanese Italian Polish Russian Chinese Other Which of the following would you say best describes your race and ethnicity?Please select all that apply. White Hispanic or Latino Black or African American Asian Native Hawiian or other Pacific Islander American Indian, Alaskan Native, or First Nation Mixed Race Prefer not to answer I don't know/I'm not sure Do you take your medication(s) (including over-the-counter) exactly as your health care provider(s) recommends?Select OneYesNoWhat is the reason(s) you are not taking your medication(s) exactly as your health care provider(s) recommends?Please select all that apply. I can't afford my medication(s) I have problems with side effects I did not fill my prescription(s) I do not see the need for medication I forget to take them I feel better, so I stopped taking them Transportation issues I don't have enough caregiver support I am on too many medications so I don't take all of them every time as ordered Other Please use this space to describe other reasons why you are not taking your medication(s) exactly as your health care provider(s) recommends?Have you ever been told by a health care provider that you had or have any of these conditions?Please select all that apply. Diabetes Heart Failure (HF) Coronary Artery Heart Disease (CAD) Chronic Obstructive Pulmonary Disease (COPD) Asthma HIV/AIDS Back Pain Cancer of any type Depression Pregnancy Pre-diabetes, borderline diabetes, impaired fasting glucose, high blood sugar Weight-related condition (obesity, overweight, or underweight) Hypertension Angina or angina pectoris Heart attack (myocardial infarction, MI) Any other heart condition Stroke or transient ischemic attack (TIA) Ulcer (stomach, duodenal, peptic) Kidney or liver condition Arthritis Schizophrenia Bipolar disorder Chronic Pain Other None of these conditions What is your due date? MM slash DD slash YYYY What other condition(s) have you been told by a health care provider that you have?Have you had a flu shot within the past year?Select OneYesNoI don't know/I'm not sureAre you up to date on all vaccines recommended for your age and gender?(i.e., Tdap for age 19 and older every 10 years; Shingles age 60 and older)Select OneYesNoI don't know/I'm not sureHow many times in the past month have you used drugs recreationally or abusively (more than prescribed)?Select OneOne timeTwo timesThree timesMore than 3 timesI don't use drugs recreationally or abusivelyHave you EVER used tobacco or e-cigarettes with nicotine products?Select OneYesOccasional SmokerNoDo you have any other questions, fears, or concerns about your health?Over the last 2 weeks, how often have you been bothered by any of the following problems:Little interest or pleasure in doing things?Select OneNot at allSeveral daysMore than half the daysNearly every dayFeeling down, depressed, or hopeless?Select OneNot at allSeveral daysMore than half the daysNearly every dayIf you would like to speak with someone about your mental health, please contact your PCP and/or behavioral health provider, or reach out to one of these organizations: • 988 Suicide and Crisis Lifeline • 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 Social Determinants of HealthDo any of the following create barriers that interfere with your ability to get care for yourself/your child?Please select all that apply. Transportation Housing Clothing Food Finances Employment Lack of support system Language barrier Cultural barrier Lack of motivation High level of stress Caregiver responsibilities Exposure to crime, violence, social disorder Residential isolation and/or other forms of discrimination Lack of access to emerging technologies Difficulty interacting with others Health beliefs and behaviors Other None Please list other barriers that interfere with your ability to get care for yourself/your child. Member Communication ConsentHow would you prefer that we contact you? Phone Mail Email Text Community First Member Portal Other If you'd like us to contact you in another way, please describe it here.Do you consent for Community First Health Plans to communicate information electronically through a secure system that is designed to keep your information safe? You will be notified via email or SMS text when there is secure information for you to review. The email or SMS text will contain a link that will take you to a secure site. After clicking on the link, you will be required to login to access your information.* Yes No NameThis field is for validation purposes and should be left unchanged. Δ
