Member Health Survey

Use our Health Survey to see if a Health Educator can help your child(ren) find a doctor, clinic, or schedule an appointment.

"*" indicates required fields

Step 1 of 6

16%

Phone

This field is for validation purposes and should be left unchanged.

Name*

First Last

Date of Birth*

MM slash DD slash YYYY

Member ID # (Located on your Community First Member ID card - Example: A0101000001)*

Age*

Email*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Do you or your spouse leave your home to plant, harvest, and pack fruits, vegetables, and nuts, or do you or your spouse work in the meat packing and/or dairy industries?*

Yes

Does your child travel with you?*

Yes

Which state are you traveling to next?*

During which month do you plan to travel for work?*

Are you familiar with the Texas Health Steps program and its current requirements?*

Yes

Do you know if your child had a Texas Health Steps visit (or Well Child exam) in the past year?*

Yes

What is the approximate date of your child’s last Texas Health Steps visit or Well Child exam?*

MM slash DD slash YYYY

Has your child visited the dentist in the past year?*

Yes

If you are unsure of your child's Medicaid dental plan or benefits, call 1-800-964-2777 or 2-1-1.

As far as you know, is your child current with their appropriate vaccines?*

Yes

If your child is NOT current with their Texas Health Steps/Well Child exam or vaccines, would you like help scheduling an appointment?*

Yes

Would you like a follow up call or an appointment reminder?

Yes

Do you consent for Community First to communicate information electronically through a secure system that is designed to keep your information safe? You will be notified via email when there is a secure information for you to review. The email will provide a link that will take you to the secure site. After clicking on the link, you will be required to login to access your information.

Yes

Do you want to opt out of Texas Health Steps and refuse to complete Texas Health Steps visits?

Yes

Does your child have any of the following medical conditions?

Asthma

Diabetes

Pregnant

Obesity

Hypertension

Behavioral Health Issues

Coronary Artery Disease

Arthritis

Congestive Heart Failure

Chronic Obstructive Pulmonary Disease

Social Determinants of Health

What type of home-setting do you currently live in?*

Apartment

Car/Motorhome

Group/Adult Home

Homeless

House

Motel/Hotel

Nursing Home/Assisted Living

Shelter

Skilled Nursing Facility

Other

I don't know/I'm not sure

I prefer not to answer this question

Have you had difficulties purchasing food, accessing healthy food, and/or getting to the grocery store?*

Yes

I don't know/I'm not sure

I prefer not to answer

What is the highest level of education you have completed?*

Less than a high school diploma

High school diploma/GED

More than a high school diploma/GED

I prefer not to answer

Do you have difficulties meeting your basic daily and/or healthcare needs related to problems accessing transportation resources?*

Yes

I don't know/I'm not sure

I prefer not to answer

Do you need assistance with internet service?*

Yes

I don't know/I'm not sure

I prefer not to answer

Mental Health Status

Over the past 2 weeks, how often have you been bothered by feeling down, depressed or hopeless?*

Not at all

Several days

More than half of the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by having little interest or pleasure in doing things?*

Not at all

Several days

More than half of the days

Nearly every day

Over the past 2 weeks, how often have you had trouble falling or staying asleep or sleeping too much?*

Not at all

Several days

More than half of the days

Nearly every day

Over the past 2 weeks, how often have you felt tired or that you had little energy?*

Not at all

Several days

More than half of the days

Nearly every day

Over the past 2 weeks, how often have you had a poor appetite or overeating?*

Not at all

Several days

More than half of the days

Nearly every day

Over the past 2 weeks, how often have you felt bad about yourself, that you are a failure, or that you have let yourself/ family down?*

Not at all

Several days

More than half of the days

Nearly every day

Over the past 2 weeks, how often have you had trouble concentrating on things, such as reading the newspaper or watching television?*

Not at all

Several days

More than half of the days

Nearly every day

Over the past 2 weeks, how often have you moved or spoke so slowly that other people could have noticed -OR- been so fidgety or restless that you have been moving around a lot more than usual?*

Not at all

Several days

More than half of the days

Nearly every day

Over the past 2 weeks, how often have you thought that you would be better off dead or of wanting to hurt yourself?*

Not at all

Several days

More than half of the days

Nearly every day

Over the past 2 weeks, how often have these problems made it difficult for you to do your work, take care of things at home, or get along with other people?*

Not at all

Several days

More than half of the days

Nearly every day

If you feel you need to speak with someone about your mental health, please contact your PCP and/or behavioral health provider or reach out to one of the organizations listed below:

The 988 Suicide and Crisis Lifeline: Call or text 9-8-8 (text is English only)
Center for Health Care Services 24-hour Crisis Line: 800-316-9241 or 210-223-SAFE (7233)
SAPD Public Safety Unit: 210-207-7273
Bexar County Sheriff: 210-335-6000
Poison Control: 800-222-1222
Members can also call 2-1-1 or visit 211texas.org to locate a Behavioral Health professional.

Member Health Survey

Social Determinants of Health

Mental Health Status

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