CHILD HEALTH ASSESSMENT

The following questions will help University of Utah Health Plans give your child the best care possible. The answers will not affect their benefits. Our Care Managers will review your answers, and may reach out to assist you with your healthcare needs.


Member Information

Sender Information

Assessment Questions

Do you need a Translator?
Has your child been diagnosed with any of the following?
Does your child have trouble with speech?
Does your child use an assistive device to communicate?
Does your child have trouble with hearing?
Does your child have trouble with vision?
Does your child use any other assistive devices or services to help with their vision?
Does your child use any other assistive devices for daily activities like dressing, eating, or walking?
Does your child need therapy?
Does your child take any medications regularly?
Does your child see a doctor for any behavioral health issues?
Has your child been hospitalized in the last 6 months?
Has your child been in the emergency room in the past 6 months?
Has your child’s doctor ever told you that your child is overweight?
Is your child up-to-date on their immunizations?
Was your child seen for a Well Visit in the past 12 months?
Do you need help getting enough food for your child?
Does your child have safe, stable housing?
Has your child experienced any trauma in the past 6 months?
Do you have any other concerns about your child?