Healthier You! New Beginnings Submission Form URLThis field is for validation purposes and should be left unchanged.Hit reset on your health for 2026! Fill out the Community First Health Assessment to see if you can benefit from joining a Community First Health & Wellness Program! Already completed the Health Assessment or participating in a program? Tell us how the program supports your health or how you’re using your health plan benefits to stay healthy in the new year. Submit the form and earn a FREE Healthier You! Sleep Kit, packed with everything you need to rest and recharge.Questions? Call 210-358-6055 or email healthyhelp@cfhp.com. Member ID (Located on your Community First Member ID card - Example: A0101000001)*Name* First Last Phone*Email* Date of Birth (MM/DD/YYYY)* MM slash DD slash YYYY Shipping Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Are you currently enrolled in a Health & Wellness Program?* Yes No Which Health & Wellness program(s) are you currently enrolled in?*Please select all that apply Asthma Matters Diabetes in Control Healthy Expectations Healthy Heart Healthy Living Healthy Mind Please tell us how this program will help you achieve your 2026 goals.* Height* Feet Inches Weight*Body Mass Index (BMI)*Calculate your BMI HERE Health ConcernsHow would you rate your overall health?* Excellent Good Fair Poor Very Poor Social FactorsWhat is your preferred language?*Please select all that apply. English Spanish French German Arabic Hebrew Japanese Italian Polish Russian Chinese Other Please describe "Other" preferred language here.*Which of the following race(s) and ethnicity(ies) do you identify with? 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 MedicationHow many prescription medications do you take on a regular basis? (daily, every other day)* 1-2 3-4 5-7 8-10 Over 10 Do you take your medication(s) (including over-the-counter) exactly as your health care provider(s) recommends?*Select OneYesNoWhat are the reasons you are not taking your medications exactly as your health care provider(s) recommends?*Please select all that apply. Can't afford medications Problems with side effects Did not fill prescriptions Does not see need for medication Lack of knowledge about medication use Other Forget to take them Forget to bring the medication with me when traveling or leaving home I feel better so I stopped taking them Transportation issues Inadequate caregiver support I am on too many medications so I don't take all of them every time as ordered If there are 'Other' reasons you do not take your medications exactly as ordered, please explain.*Medical HistoryWhich of these conditions have you ever been told you have by a health care provider?*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 Other None of these conditions Pre-diabetes, borderline diabetes, impaired fasting glucose, high blood sugar 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 What 'Other' condition(s) were you told of?*VaccinationsHave 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 sureDrug and Alcohol UseHow 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 abusivelyFOR MEN: How many times in the past month have you had more than 4 alcoholic drinks in one day or more than 14 total in one week?*Select OneOne timeTwo timesThree timesMore than 3 timesI don't drink alcoholFOR WOMEN: How many times in the past month have you had more than 3 drinks of an alcoholic drink in one day or more than 7 total in one week? (alcoholic beverage such as beer, wine, a malt beverage or liquor)*Select OneOne timeTwo timesThree timesMore than 3 timesI don't drink alcoholTobacco/E-Cigarette Usage or ExposureHave you EVER used tobacco or e-cigarettes with nicotine products?*Select OneYesOccasional SmokerNoDo you currently use tobacco or e-cigarettes with nicotine products? (If your answer is 'No', please do not check any other answer)* Cigarettes Cigars Pipe tobacco (non-ceremonial) Smokeless tobacco No E-Cigarettes with nicotine Other tobacco products Are you exposed to secondhand smoke?*Select OneAlwaysOftenSometimesRarelyNeverSocial Determinants of HealthWhich of the following create barriers to being healthy and getting the health care you need?*Please select all that apply. Transportation Housing Food Caregiver responsibilities Other None Please describe the 'Other' barriers you have to being healthy and getting the health care you need.*Mutuality/Self-ManagementWhat other questions, fears, or concerns do you have about your health?*How would you prefer that we contact you?* Phone Mail Email Text Δ
