Health Assessment

General Care Initial Assessment

How would you rate your overall health?

Excellent
Good
Fair
Poor
Very Poor

What is your preferred language?

Which of the following would you say best describes your race and ethnicity?

Please select all that apply.

White
Hispanic or Latino
Black or African American
Asian
Native Hawiian or other Pacific Islander
American Indian, Alaskan Native, or First Nation
Mixed Race
Prefer not to answer
I don't know/I'm not sure

Do you take your medication(s) (including over-the-counter) exactly as your health care provider(s) recommends?

What is the reason(s) you are not taking your medication(s) exactly as your health care provider(s) recommends?

Please select all that apply.

Please use this space to describe other reasons why you are not taking your medication(s) exactly as your health care provider(s) recommends?

Have you ever been told by a health care provider that you had or have any of these conditions?

Please select all that apply.

What is your due date?

What other condition(s) have you been told by a health care provider that you have?

Have you had a flu shot within the past year?

Are you up to date on all vaccines recommended for your age and gender?

(i.e., Tdap for age 19 and older every 10 years; Shingles age 60 and older)

How many times in the past month have you used drugs recreationally or abusively (more than prescribed)?

Have you EVER used tobacco or e-cigarettes with nicotine products?

Do you have any other questions, fears, or concerns about your health?

Over the last 2 weeks, how often have you been bothered by any of the following problems:

Little interest or pleasure in doing things?

Feeling down, depressed, or hopeless?

If you would like to speak with someone about your mental health, please contact your PCP and/or behavioral health provider, or reach out to one of these organizations: • Suicide and Crisis Lifeline: 988 • 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 (BH) professional

Social Determinants of Health

Do any of the following create barriers that interfere with your ability to get care for yourself/your child?

Please select all that apply.

Please list other barriers that interfere with your ability to get care for yourself/your child.

Step 1 of 3 - General Information

General Care Initial Assessment

Over the last 2 weeks, how often have you been bothered by any of the following problems:

Social Determinants of Health

Member Communication Consent

Questions?

We’re here to help. Email healthyhelp@cfhp.com or call (210) 358-6055 for more information.

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