Health Needs Survey. Demographic Information. m Male m Female
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1 Health Needs Survey m m Please fill in your responses like this using ONLY A BLUE OR BLACK PEN. Do NOT use GREEN INK. Please answer as many questions as you can. Leave blank the question(s) you cannot or choose not to answer. Name: Address: Date of Birth: What is your gender? Phone number: Demographic Information M M D D Y Y Y Y m Male m Female Why are we doing this? We want to provide you with high quality care that meets your needs. To do this, we need some information from you. The information you provide us will be kept private. The information may be shared with members of your care team (primary care provider, specialists and case manager, if needed). Your answers will be used to help us give you the best information and service possible. Please complete and return this survey. Notice: Completion of this form is considered an approval to utilize the information, as needed, to best coordinate your care. We use race, language and ethnic background to improve the quality of treatment and care that you need. We also use it to develop programs specific for you. 1. Which of these best describes your race? m American Indian/Alaskan Native m Asian m Black/African American m Native Hawaiian/Other Pacific Islander m White m Declined 2. Do you consider yourself Hispanic/Latino? m Declined m Unavailable/Unknown 3. What language do you speak? 1
2 Health History 4. Compared to others your age, how would you describe your overall health? m Excellent m Very Good m Good m Fair m Poor 5. Do you have any of the special needs or disabilities listed below? m Hearing Impairment m Deaf m Vision Impairment m Blind m Learning Disability m None 6. How much do you weigh in pounds? Pounds 7. How tall are you? Feet Inches How often do you need to have someone help you read instructions, pamphlets or other written material from your doctor or pharmacy? m Never m Rarely m Sometimes m Often m Always 2
3 Please tell us about your medical conditions 9. Has a doctor or other health care professional ever told you that you have any of the following? Check all that apply Asthma Bipolar Disorder or mood swings Cancer Chronic Obstructive Pulmonary Disease (COPD) or other breathing problems Diabetes or Sugar in Your Blood Heart Disease High Blood Pressure High Cholesterol HIV or AIDS Major Depression or feeling sad most of the time Obesity or that you are overweight Schizophrenia Sickle Cell Disease You might need a transplant 10. How many medications do you take each day? (include prescription and over-the-counter) m None m 1 to 3 m 4 to 7 m 8 to 11 m 11 or more 11. In the last three months, how often have you taken medications differently than they were prescribed? m Daily m Almost every day m Sometimes m Never 12. In the last three months, how often have you used medications not prescribed to you? m Daily m Almost every day m Sometimes m Never 13. Has your health caused you to miss time away from school, work or other activities within the last year? 3
4 14. In the past 12 months, how many times have you: Gone to the Emergency Room? m None m 1 to 2 m 3 to 5 m 6 or more Stayed overnight in a hospital? m None m 1 to 2 m 3 to 5 m 6 or more 15. Over the last 2 weeks, how often have you been bothered by any of the following? Feeling sad, down, depressed or hopeless Having little or no pleasure in doing things Feeling nervous, anxious or on edge? Not being able to stop or control worrying? 16. When was the last time that you had a colonoscopy? m Never m Within the last 10 years m More than 10 years 17. Are you pregnant? For women only, otherwise skip to question 20. If no, are you planning to get pregnant in the next 12 months? If yes, how long have you been pregnant? m 1 to 3 months m 4 to 6 months m 7 to 9 months 18. When was the last time you had a mammogram? m Never m Within the last 2 years m More than 2 years m I have had a mastectomy 19. When was the last time you had a Pap Smear? m Never m Within the last 3 years m More than 3 years m I have had a hysterectomy 4
5 Please tell us about some of your daily habits 20. Have you had a flu or pneumonia vaccine in the last year? 21. How often do you walk, run or do other exercises for 30 minutes a day that make you breathe heavier or make your heart beat faster? m Less than 1 time per week m 1 to 2 times per week m 3 times per week m 4 times per week m 5 or more times per week 22. Do you currently use tobacco products (cigarettes, chewing tobacco, cigars, pipes)? m Yes, I currently use tobacco products (For tobacco users only) In the last year, how many times have you quit using tobacco products for at least 24 hours? (For tobacco users only) Are you seriously thinking of quitting tobacco use? m Yes, within the next 30 days m Yes, within the next 6 months m No, not thinking of quitting m No, I quit within the last 6 months m No, I quit more than 6 months agot m No, I have never used tobacco products 23. How often do you use alcohol, drugs or medications which affect your mood or help you relax? m Daily m Almost every day m Sometimes m Rarely or never If the response is daily or almost every day only: Have you felt you ought to cut down on your drinking or drug use? Have people annoyed you by criticizing your drinking or drug use? Have you felt bad or guilty about your drinking or drug use? Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener) 5
6 24. Are you interested in making changes in any of the following areas? Check all that apply. Controlling your use of alcohol or drugs Healthy eating Exercising or increasing physical activity Managing stress Smoking or chewing tobacco Getting to or maintaining a healthy weight m I am not interested in making any changes at this time. Thank you for allowing us to learn more about you. We will use this information to help you live healthier. Do you need help in these languages: (Kurdish-Badinani); Español (Spanish); Ngươi Việt (Vietnamese) (Arabic); Bosanski (Bosnian); (Kurdish- Sorani); Soomaali (Somali); CoverKids language and member services are free at , Monday-Friday, 8 a.m. to 6 p.m. ET. For TDD/ TTY help call Federal and State laws protect your rights. They do not allow anyone to be treated in a different way because of: race, language, sex, age, color, birthplace, or disability. Need help? Call the Office of Non-Discrimination Compliance for free at For TTY dial 711 and ask for Cameron Hill Circle Chattanooga, TN bcbst.com BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association 6 15CKD2058 (8/15)
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KENOSHA COUNTY COMMUNITY HEALTH SURVEY 2016 Commissioned by: Aurora Health Care Children s Hospital of Wisconsin United Hospital Systems In Partnership with: Center for Urban Population Health Kenosha
Mental Health Referral Form
Mental Health Referral Form Mailing Address: Niagara Region Mental Health 3550 Schmon Parkway, Second Floor, Unit 2 P.O. Box 1042 Thorold, ON L2V 4T7 905-688-2854 Toll free: 1-888-505-6074 niagararegion.ca/health