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 #:
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.
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?:
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?:
No Yes
Name of your Doctor:
No Yes
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:
No Yes
Name of your childrens' Doctor:
No Yes
Name of child(ren) with special healthcare problem(s):
Cancer
Asthma
Diabetes
Sickle Cell disease
Hemophilia
Substance use
None
Other conditions
Other: Please write the specific issue:
No Yes Not sure
If 'no' or 'not sure,' please list the names of the children who might need more shots:
No Yes
If 'no,' please list the names of the child(ren) whom have not had a check-up in the past year.
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: