Univeristy of Utah Health Plans - Health Risk Assessment

Member Information

Name

Date of Birth

Member ID

Primary Doctor

Phone Number

Height

feet

inches

Weight (lbs)

Street Address

Address 2

City

State

Zip Code

What is your gender? Male Female Trans Male / Trans Man Trans Female / Trans Woman Gender Queer/Gender Non-Conforming Different identity Prefer not to answer

What is your primary race/ethnicity? American Indian / Alaska Native Asian Black / African American Hispanic / LatinX Native Hawaiian / Other Pacific Islander White Different identity Prefer not to answer

Assessment Questions

In general, how would you rate your health?

Do you have a medical provider that you see regularly?

Yes

Do you have any hearing problems for which you need help such as a hearing aid or TTY (teletypewriter)?

Yes

Are you currently pregnant?

Yes

Not applicable

In the last 7 days, how often did you exercise for at least 20 minutes in a day?

How many alcoholic drinks (like wine, beer, mixed drinks) do you have in a normal week?

Do you use tobacco products including cigarettes, smokeless tobacco, cigars, e-cigarettes?

Yes

Have you fallen in the last 6 months?

Yes

Over the past 2 weeks, how often have you felt down, depressed or hopeless?

Over the past 2 weeks, how often have you felt little interest or pleasure in doing things?

How stressful is your life right now?

During the past 4 weeks, did any medical problem keep you from being able to work or do any activities in your normal day?

Yes

Do you have a disability?

Yes

In the past 7 days, how much pain have you felt?

How many prescription drugs do you take?

How many times in the last 6 months have you been to the emergency department?

How many times were you hospitalized in the last 12 months?

Do you need assistance with the following activities? (Select all that apply)? Bathing Dressing Brushing Hair / Teeth Eating Getting out of bed or chair Walking Climbing Stairs Using the bathroom None of the above

Do you need any medical equipment?

Yes

Do you have access to transportation for medical appointments?

Yes

Do you need help with food, clothing, housing, or utilities?

Yes

How long has it been since you last visited a dentist or dental clinic?

What is your main health concern right now?

How confident are you that you can control and manage, most of your health problems?

ADULT HEALTH ASSESSMENT

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