Health Needs Survey Form

Your First Name:

Your Last Name:

Date of Birth:

Medicaid ID #:

Primary Care Provider:

Address:

Email address:

Do we have permission to contact you by email/text?

Yes

Telephone (Home):

Telephone (Mobile):

Telephone (Work):

The language(s) we usually speak at home:

English

Spanish

Other

Other (Please write here):

Child 1: First Name:

Child 1: Last Name:

Child 1: Date of Birth:

Child 1: Medicaid ID #:

Child 1: Primary Care Provider:

Child 1: Are they up-to-date with all their shots?

Yes

Not Sure

Child 2: First Name:

Child 2: Last Name:

Child 2: Date of Birth:

Child 2: Medicaid ID #:

Child 2: Primary Care Provider:

Child 2: Are they up-to-date with all their shots?

Yes

Not Sure

Child 3: First Name:

Child 3: Last Name:

Child 3: Date of Birth:

Child 3: Medicaid ID #:

Child 3: Primary Care Provider:

Child 3: Are they up-to-date with all their shots?

Yes

Not Sure

Child 4: First Name:

Child 4: Last Name:

Child 4: Date of Birth:

Child 4: Medicaid ID #:

Child 4: Primary Care Provider:

Child 4: Are they up-to-date with all their shots?

Yes

Not Sure

1. Does your child need or use more medical care, mental health or educational services than is usual for most children of the same age?

Yes

If yes, name of child(ren):

If yes, is this because of any medical or behavioral health condition?

Medical condition

Behavioral health condition

2. Does your child currently need or take medication prescribed by a doctor (other than vitamins)?

Yes

If yes, name of child(ren):

If yes, is this because of any medical or behavioral health condition?

Medical condition

Behavioral health condition

3. Is your child limited or prevented in any way in their ability to do the things most children of the same age can do?

Yes

If yes, name of child(ren):

If yes, is this because of any medical or behavioral health condition?

Medical condition

Behavioral health condition

4. Does your child have any kind of emotional, developmental, or behavioral problem for which they need or get treatment or counseling?

Yes

If yes, name of child(ren):

If yes, is this because of any medical or behavioral health condition?

Medical condition

Behavioral health condition

If other, please write specific issue:

If yes, name of child(ren):

6. Does your child have any of the following health conditions?

Vision Loss

Hearing Loss

Physical Disability

Mental Disability

Learning Disability

None

Other Condition

If other, please write specific issue:

If yes, name of child(ren):

7. Has your child had a regular check-up with their doctor in the last year?

Yes

8. Has your child seen a dentist in the last year?

Yes

9. Does your child often feel overwhelmed with stress and anxiety?

Yes

10. During the past year, were you or anyone in your family admitted for an overnight stay in a hospital?

Yes

Name of Person 1 admitted:

For what problem?:

Name of Person 2 admitted:

For what problem?:

Name of Person 3 admitted:

For what problem?:

11. During the past year, have you or anyone in your family received medical care in a hospital emergency room?

Yes

Name of Person 1 admitted:

For what problem?:

Name of Person 2 admitted:

For what problem?:

Name of Person 3 admitted:

For what problem?:

Other Condition (please write specific issue):

13. How many different prescription and over-the-counter medications do you take each day?

1 - 3

4 - 7

8 or more

14. Have you received any of the following services in the past year?

Yearly Check-up

COVID-19 Vaccine

Vision Screening

Cervical Cancer Screening/Pap Smear

Colorectal Screening

Flu Shot

Mammogram

15. Are you, or anyone in your household pregnant now? If yes, please provide the following information. Include yourself if it applies.

Yes

Name of Person 1:

Date of Birth of Person 1:

Due Date of Person 1:

Name of Person 2:

Date of Birth of Person 2:

Due Date of Person 2:

Have you or they seen a doctor for this pregnancy?

Yes

Have you or they been told this is a high-risk pregnancy?

Yes

Are you or they on any prescription medications for pain, or other narcotics?

Yes

16. Is it hard for you to concentrate, remember things, or make decisions?

Yes

17. Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things?

Not at all

Several days

More than half the days

Nearly every day

No Response

18. Over the last two weeks, how often have you been feeling down, depressed or hopeless?

Not at all

Several days

More than half the days

Nearly every day

No Response

20. Has alcohol or drug use made it hard for you to work, keep relationships, or meet goals?

Yes

21. What is your housing situation today?

I have housing

I have temporary housing

I have housing, and part of my rent is paid by a housing assistance program

I do not have housing

22. Have you aged out of the foster care system in the last year?

Yes

23. In the past year, have you spent more than two nights in a jail or prison?

Yes

24. Do you feel physically and emotionally safe where you live right now?

Yes

25. Do you use tobacco products or vape?

Yes

If yes, are you interested in quitting?

Yes

You do not need to sign in to complete this survey.

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