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Health Survey Form

Welcome to Health Plan of Nevada! We will do our best to keep you healthy and give you quality medical care. Please take a few minutes to fill out this form. We want to be able to contact you and to know about your special health care needs. Your benefits will not be reduced because you answered these questions. If you need help filling out this form, call us at 1-800-962-8074, TTY 711 between 8 a.m. and 5 p.m. Monday through Friday.

You may also choose to download a PDF version of the form to be filled out and mailed in.

Family members enrolled in Health Plan of Nevada's Medicaid or Nevada Check Up Program are:

Adult 1: Name:

*

Adult 1: Date of Birth:

*

Adult 1: Medicaid #:

*

Address:

*

Email address:

*

Telephone (Home):

*

Telephone (Mobile):

*

Telephone (Work):

*

Adult 2: Name:

Adult 2: Date of Birth:

Adult 2: Medicaid #:

Address:

Email address:

Telephone (Home):

Telephone (Mobile):

Telephone (Work):

Adult 3: Name:

Adult 3: Date of Birth:

Adult 3: Medicaid #:

Address:

Email address:

Telephone (Home):

Telephone (Mobile):

Telephone (Work):

Adult 4: Name:

Adult 4: Date of Birth:

Adult 4: Medicaid #:

Address:

Email address:

Telephone (Home):

Telephone (Mobile):

Telephone (Work):

Child 1: Name:

Child 1: Date of Birth:

Child 1: Medicaid #:

Child 2: Name:

Child 2: Date of Birth:

Child 2: Medicaid #:

Child 3: Name:

Child 3: Date of Birth:

Child 3: Medicaid #:

Child 4: Name:

Child 4: Date of Birth:

Child 4: Medicaid #:

The language(s) we usually speak at home:

English

Spanish

Other (Please write here):

Please answer these questions to help us take better care of you and your family members who are enrolled in Health Plan of Nevada: ** Please note these answers are confidential as governed by Federal and State Law, and will only be used to assist you with your medical care.

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

Yes

No

Name of Person 1 admitted:

For what problem?:

Name of Person 2 admitted:

For what problem?:

Name of Person 3 admitted:

For what problem?:

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

Yes

No

Name of Person 1 admitted:

For what problem?:

Name of Person 2 admitted:

For what problem?:

Name of Person 3 admitted:

For what problem?:

3. Do you have a Primary Care Provider? (Example: OB/GYN or Family Medicine)

No

Yes

Name of your Doctor:

Have you ever been told you have one or more of the following medical conditions?

No

Yes

Please check the box(es) for the problem(s) that apply:

Cancer

Heart attack, heart bypass surgery, or a stent

Heart Failure or enlarged heart

High Blood Pressure

Asthma, COPD, or other breathing problems

ESRD or currently on dialysis

Sickle Cell Disease

HIV/AIDS

Hemophilia

Diabetes or sugar problems

Depression OR Major Depression

Eating disorder

Significant Memory Loss or Dementia

Bi-Polar Disorder

Schizophrenia or other psychotic disorders

Anxiety Disorder

SUD (Substance Use Disorder)

Intellectual/Developmental Disability

None

Other Conditions

Other: Please write specific issue:

4. Does your child(ren) have a Primary Care Provider? (Example: Pediatrician)

No

Yes

Name of your childrens' Doctor:

Does he/she see this doctor for any special healthcare problem(s)?

No

Yes

Name of child(ren) with special healthcare problem(s):

Please check the box(es) for the problem(s) that apply:

Cancer

Asthma

Diabetes

Sickle Cell disease

Hemophilia

Substance use

None

Other conditions

Other: Please write the specific issue:

5. Are each of your children up to date with all of their shots?

No

Yes

Not sure

If 'no' or 'not sure,' please list the names of the children who might need more shots:

6. Has each child had a regular check-up with their doctor in the past year?

No

Yes

If 'no,' please list the names of the child(ren) whom have not had a check-up in the past year.

7. Are you, or anyone in your family pregnant now?

No

Yes

If 'yes,' please provide additional information. Include yourself if it applies. Name:

Date of Birth:

Due Date:

Name:

Date of Birth:

Due Date:

Name:

Date of Birth:

Due Date:

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