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Health Risk Assessment
2027 HRA (IR_812)
Background:
Are you submitting this form as a Member or an Agent?
*
Member
Agent
Agent NPN
Medicare ID / MBI
*
Imperial Member ID
Plan Start Date
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number
Format: (000) 000-0000.
Gender
*
Male
Female
N/A
County
*
Please Select
Please Select
Alameda
Amador
Butte
Contra Costa
Del Norte
El Dorado
Fresno
Glenn
Humboldt
Imperial
Inyo
Kern
Kings
Los Angeles
Madera
Marin
Mariposa
Mendocino
Merced
Modoc
Mono
Monterey
Napa
Nevada
Orange
Placer
Plumas
Riverside
Sacramento
San Benito
San Bernardino
San Diego
San Francisco
San Joaquin
San Luis Obispo
San Mateo
Santa Barbara
Santa Clara
Santa Cruz
Shasta
Siskiyou
Solano
Sonoma
Stanislaus
Sutter
Tehama
Tulare
Tuolumne
Ventura
Yolo
Yuba
Email (Optional)
example@example.com
Preferred Language (Optional):
English, Spanish, etc.
Religion (Optional):
Highest Education Level (Optional):
Section 1:
About You (Personal Characteristics)
What is your race and/or ethnicity? Select all that apply and enter details in the space provided.
*
American Indian/Alaskan Native
Asian
Black/African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian/Pacific Islander
White
Other Group, please write in:
Section 2:
Health Conditions
Have you ever had any of these health problems? Check all that apply.
*
Asthma
Arthritis or Joint Problems
HIV or AIDS
COPD
Irregular Heartbeat
Diabetes
Prediabetes
Stroke (incl. Brain Bleed)
High Blood Pressure
Heart Attack (MI)
Substance Use Disorder
Bladder Problems
Heart Failure
Bowel Problems
Kidney Disease
Hearing Loss
Dementia or Memory Loss
Obesity
Liver Disease
Seizures
Heart Disease
Paralysis
Cancer
Mental Health Disorder
Substance Use Disorder
Past Organ Transplant(s)
None
Other:
If you selected Cancer, what type?
If you selected Mental Health Disorder, what type?
If you selected Past Organ Transplant(s), which organ?
Transplant Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Section 3:
Your Health & Doctor Visits (Preventive Care)
How would you rate your current health?
*
Excellent
Very Good
Good
Fair
Poor
How confident are you filling out medical forms by yourself?
*
Extremely Confident
Somewhat Confident
Not Confident
In the event of a Medical emergency: (select one)
*
I want to have life-support treatment
I do not want life-support treatment
I am unsure and would like more information
Have you had any problems with memory?
*
Yes
No
Do you have a good understanding of your healthcare?
*
Yes
No
When was your last check-up?
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
When was your last mammogram?
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
When was your last blood test?
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
When was your last colon cancer screening?
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you regularly do any kind of physical activity or exercise?
*
Yes
No
Have you been offered a palliative care visit to help manage chronic conditions?
*
Yes
No
Overall, how comfortable are you with performing these activities of daily living?
*
Rows
Can do independently
Need Assistance
Eating
Dressing / Undressing
Using the toilet
Brushing hair / teeth, shaving, clipping nails, etc.?
Getting in and out of bed and moving around freely
Bathing or showering completely
Do you require assistance with any of the following? (Check all that apply)
*
Managing medications
Managing finances
Shopping for groceries or necessities
Preparing meals
Housekeeping or laundry
Transportation to appointments or errands
Using the telephone or other communication devices
Managing appointments or daily activities
None - Independent with all Independent Activity Daily Living with all of the above
If you have diabetes or a heart condition, are you taking a statin (cholesterol medicine)?
*
Yes
No
If no (not taking a statin), select all that apply below:
Side effects, allergy, or intolerance (e.g., muscle pain or weakness)
Liver problems, End Stage Kidney disease, or dialysis
Prediabetes or other blood sugar concerns
Do not think I need a statin / cholesterol is normal
Taking another cholesterol-lowering medication
Cost issues or difficulty getting medication
Other:
Were your eyes dilated at an exam in the last 2 years?
*
Yes
No
If yes, Drs. Name:
If yes, when was the dilated retinal (eye) exam?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Was retinopathy found?
Yes
No
When was your last blood test?
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What was the A1c level (if known) from your last blood test?
*
example: 5.7
When was your last blood pressure reading?
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What were the BP levels (if known) of your last blood pressure reading?
*
example: 120/80
Location of BP Reading:
*
Home
Doctor's Office
How often do you use the following:
*
Rows
Regularly
Occasionally
Never
Tobacco
Alcohol
Recreational Drugs
Have you received any of the following vaccines this year?
*
Flu
Pneumonia
COVID
None
Other vaccine:
If you do not get vaccinated regularly, why?
How would you describe your eating habits?
*
Healthy and balanced
Somewhat healthy
Unhealthy or not regular meals
How many times have you been admitted to a hospital in the past 12 months?
*
0
1-2
3-5
More than 5 times
How many times have you gone to the emergency room (ER) in the past 12 months?
*
0
1-3
4-7
More than 7 times
Have you had any stays at a Skilled Nursing Facility (SNF) or Acute Rehab Facility in the past 12 months?
*
Yes
No
Section 4:
Moving and Balance (Risk of Falling)
Have you fallen in the past year?
*
Yes
No
Do you feel unsteady while walking or standing?
*
Yes
No
Do you use assistive devices to walk or stand?
*
Yes
No
If yes, what type of device?
Do you hold onto furniture when walking at home?
*
Yes
No
Do you have trouble seeing clearly?
*
Yes
No
Have you had a vision test in the past year?
*
Yes
No
Section 5:
Medicines, Allergies, & Pain
Do you take prescription medicines?
*
Yes
No
If yes, how many?
Do you get extra help from Medicare to pay for your medications?
Yes
No
List all known medications (if possible):
Do you ever have difficulty taking your medications exactly as prescribed?
Yes
No
If yes, select all that apply below.
Cost
Forgot to take/refill medication
Side effects
Medication not effective
Difficulty obtaining medication
Waiting for provider/refill authorization
Doesn't understand medication instructions
Too many medications/complex regimen
Provider discontinued medication
Other:
Do you have any side effects from your medications such as dizziness, sleepiness, dry mouth, constipation, blurry vision, confusion, or trouble thinking? (Common examples include some medicines for allergies, bladder problems, depression, sleep or stomach issues.)
Yes
No
Not sure
If yes, can you list the names of those medicines (or describe what they are for)?
Do you have any known allergies?
*
Yes
No
If yes, list the allergens:
Do you currently have pain or discomfort?
*
Yes
No
If yes, where?
What is the level of pain on a scale from 0-10?
0 = No Pain, 10 = Worst Ever
Section 6:
Support & Social Life
Do you feel safe at home?
*
Yes
No
Do you have a caregiver helping you now?
*
Yes
No
If yes, how many days each week?
Do you ever think your caregiver has a hard time giving you all the help you need?
*
Yes
No
Who do you have to help you when needed?
*
Family
Friends
Caregivers (ex: IHSS)
No help
How often do you speak with or see close friends/family?
*
Less than once a week
1-2 times a week
3-5 times a week
More than 5 times a week
Section 7:
Housing & Transportation
What is your housing situation today?
*
I have a steady place to live
I have a place to live today, but I am worried about losing it in the future
I do not have a steady place to live (I am staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)
In the past 12 months, has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? (check all that apply)
*
Yes, it has kept me from medical appointments or getting medications
Yes, it has kept me from non-medical meetings, appointments, work or getting things that I need
No
Section 8:
Food & Utilities
Within the past 12 months, you worried that your food would run out before you got money to buy more.
*
Often true
Sometimes true
Never true
In the past 12 months has the electric, gas, oil, or water company threatened to shut off services in your home?
*
Yes
No
Already shut off
Section 9:
Mood and Emotional Health
In the past two weeks, how often have you been bothered by any of the following problems?
*
Rows
Not at all
Several days
More than half the days
Nearly every day
Lost interest or joy in things:
Feeling down, depressed, or hopeless:
Submit
Should be Empty: