Health Needs Survey Form

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

Welcome to UnitedHealthcare Health Plan of Nevada Medicaid! Your health is important to us. That’s why we need a little more information to help provide you and your family with quality care to meet your medical needs. Please take a few minutes to fill out this form. Each adult in the home needs to complete their own form. Your answers are confidential and will only be used to assist you and your family with medical care. If you need help filling out this form, call us toll-free at 1-800-962-8074, TTY 711, Monday through Friday, 8 a.m. to 5 p.m. If we have any questions, we may reach out to you.

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

Please answer the following questions:

Your First Name:

The Your First Name: field is required.

Your Last Name:

The Your Last Name: field is required.

Date of Birth:

The Date of Birth: field is required.

Medicaid ID #:

The Medicaid ID #: field is required.

Primary Care Provider:

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

Yes No

The language(s) we usually speak at home:

English Spanish Other

Other (Please write here):

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

Child 1: First 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?

No Yes Not Sure

Child 2: First 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?

No Yes Not Sure

Child 3: First 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?

No Yes Not Sure

Child 4: First 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?

No Yes Not Sure

Please answer these questions to help us take better care of you and your family members who are enrolled in Health Plan of Nevada: Your answers are confidential as governed by Federal and State Law, and will only be used to assist you with your medical care. If there are no children in your household, please skip to question #10.

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?

No 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)?

No 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?

No 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?

No 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?

No Yes

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

No Yes

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

No Yes

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

No Yes

Name of Person 1 admitted:

Name of Person 2 admitted:

Name of Person 3 admitted:

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

No Yes

Name of Person 1 admitted:

Name of Person 2 admitted:

Name of Person 3 admitted:

Other Condition (please write specific issue):

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

0 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.

No Yes

Date of Birth of Person 1:

Due Date of Person 1:

Date of Birth of Person 2:

Due Date of Person 2:

Have you or they seen a doctor for this pregnancy?

No Yes

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

No Yes

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

No Yes

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

No 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?

No 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

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Health Needs Survey Form

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

Please answer the following questions:

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