KelseyCare Advantage - Health needs Questionnaire

= Required Field

Name:  
Date of Birth:  
Medicare ID#:  

1.
Have you ever been treated for the following? (Check all that apply.) 





 
2.
What medical equipment do you have in your home? (Check all that apply.) 



 
3.
Have you been hospitalized in the past 6 months? 
 
4.
How many times have you been to the emergency room in the past year? 

 
5.
Do you have surgery planned in the next 3 months? 
 
6.
In general, how would you rate your health? 


 
7.
Over the last two (2) weeks, how often have you had little interest or pleasure in doing things? 

 
8.
Do you need help with any of these: 



Other:
 
9.
How many prescription medications do you take daily? 

 
10.
Please list all medications you are currently taking. Please include medication name, dose on the bottle and how often you take it (for example: once a day).

Acknowledgement

By submitting this questionnaire, I acknowledge and understand the following; I acknowledge that the information completed on this form is accurate to the best of my knowledge. I understand that my participation in this program is voluntary. I also understand that KelseyCare Advantage and any representatives may share this information with appropriate members of the KelseyCare Advantage Plan Network, which I have selected to provide for my health care needs. This may include my Primary Care Physician, Specialists and other health care providers to whom I may be referred, and hospital representatives. I understand that KelseyCare Advantage will treat this information in a confidential manner, and will not share it with anyone unrelated to my health care needs, and that this information will not impact my health insurance coverage.


H0332_EN1041a_110308