Health Survey Form

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):

1. 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?:

2. 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?:

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

Yes

Name of your Doctor:

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

Yes

Other: Please write specific issue:

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

Yes

Name of your childrens' Doctor:

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

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?

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?

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?

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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