Beruflich Dokumente
Kultur Dokumente
Welcome to Generations Healthcare HMO! We know that one of the best ways for us to understand your
healthcare needs is to ask you about them, and listen. Hearing from you helps us work with you and your
doctor to help improve, preserve and enjoy your health —an important part of our Healthy CollaborationSM.
Please take a moment to fill out this short and confidential health survey. Complete it as thoroughly as you
can. The more we understand your health needs, the better we can serve you. (Don’t worry, your answers
will in no way affect your premium or your benefits.) When completed, simply mail the postage-paid survey
back to us. Thank you.
Please enter your name:
First:_ _____________________________ Last:____________________________________ Phone:__________________________
Address: __________________________________________________________________________________________________________
Please enter the name of the doctor you see most often:
First:_ _____________________________ Last:____________________________________ Phone:__________________________
Address: __________________________________________________________________________________________________________
How often do you see your family doctor?
q Weekly q Monthly q 4-6x yr q 1x yr q less than 1x yr
1. Select the word that best describes your health: 8. Over the last two weeks:
q Good q Fair q Poor a. have you had little interest or pleasure in doing
things? q Yes q No
2. Do you live? b. felt down, depressed or hopeless?
q Home alone q with Family q Yes q No
q in a nursing home or assisted living facility
9. Please indicate any health conditions you
3. Have you fallen one or more times in the past currently have:
six months? q Yes q No q Diabetes q Stroke
q Heart problems q Breathing problems
4. Do you have any difficulty doing the following?
q Walking q Rising from a chair 10. In the last 6 months have you been in one of
q Bathing/Toileting q Eating/Preparing meals the following? q Hospital q ER
q Dressing q Driving/Transportation
q Housekeeping q Managing finances 11. Do you have surgery planned in the next
60 days? q Yes q No
5. How often do you exercise?
q Daily q Once or twice a week 12. Are you taking your medications as prescribed
q Less than once a month q Never by your doctor? q Yes q No
6. Do you currently use tobacco products, including 13. How many medications do you take on average?
chewing tobacco? q Yes q No q 5 or less q 6 to 10 q 11 to 19 q 20+
HOUSTON TX 77274-9917
PO BOX 742408
GENERATIONS HEALTHCARE HMO
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