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Health Risk Assessment Form

Your responses will be kept private and confidential.
About You
1. Name of person or child with CHIP, STAR Medicaid, or MAO DSNP:  
2. What is the date of birth of the person in question #1? mm/dd/yyyy  
3. Are you or your child male or female:  
4. What is your relationship to this child?  
5. What is your or your child's primary language? English
General Health
6. In general, would you say that your or your child's health is:  
7. How tall are you or your child?   
8. How much do you or your child weigh?  
9. What is your or your child's body mass index (BMI)?  
10. What was your or your child's birth weight?  
11. Were you or your child born prematurely, that is, more than 3 weeks before his or her due date?  
Special health care needs
12. Do you or your child currently use any medicine prescribed by a doctor, other than vitamins?  
13. Is your or your child's need for medicine because of ANY medical, behavioral, or other chronic illness (i.e., diabetes type 1 or 2, asthma, high blood pressure, etc)?  
14. Is this a condition that has lasted or is expected to last 12 months or longer?  
15. Has a doctor, health care provider, teacher, or school official ever told you that you or your child has a learning disability?  
16. Would you describe the learning disability as:  
Type of Coverage/Access to Healthcare and Utilization
17. Do you or your child have STAR, CHIP or MAO DSNP?  
18. Is there a place that you USUALLY go to or take your child to when you or your child is sick or need advice about your's or your child's health?  
19. What kind of place is it?  
20. During the past 12 months or since birth,did you or your child see a doctor, nurse, or other health care professional for any kind of medical care, inlcuding sick-child care, well-child check ups, physical exams, and hospitalizations?  
21. During the past 12 months have you or your child seen a dentist for dental check ups, cleanings, x-rays, or filling cavities?  
22. Mental health professionals include psychiatrists, psychologists, psychiatric nurses, and clinical social workers. During the past 12 months have you or your child received any care from a mental health professional?  
Medical Home
23. Do you or your child have a primary care doctor?  
23a. Who is your or your child's primary care doctor?  
24. During the past 12 months have you or your child needed a referral to see any specialists?  
25. Was getting a referral a big problem, a small problem, or not a problem?  
26. Overall are you satisfied with the communication among your child's doctors and yourself and/or other doctors or professionals?  
28. Does anyone living in your home smoke cigarettes, cigars, or pipe tobacco?  
29. Do you or anyone smoke inside your or your child's home?  
30. If you smoke, are you willing to quit?  
31. Is it hard meeting basic needs for yourself or your family? For example: buying groceries, gas, clothes, school supplies, etc  
32. Do you currently receive food stamps, TANF, housing, or another form of assisstance?  
33. Do you or the parents or legal guardians of your child work full time jobs? (8 hours a day, 40 hours a week)  
34. What is the main source of income?  
35. What is your highest level of education or of that of the mother or legal guardian?  
36. What is your highest level of education or of that of the father or legal guardian?  
37. I or my child eats vegetables:  
38. I or my child eats fruits:  
39. I or my child eats out:  
40. I or my child is active:  
41. My child has sweet drinks (cola, sweet tea, juice, sports drinks, other juice drinks):  
42. I or my child drinks water:  
43. I or my child watches television or spends time on the computer or playing video games:  
44. Have you thought about tyring a new healthy habit for yourself or your family or child?  
45. If you could work on one healthy habit, which would it be?