Health Risk Assessment Form - Coventry Health Care Of Florida printable pdf download

In order for the health plan to help you with all of your health care needs, please fill out the Health Risk Assessment (HRA) form and return it to us.

Thank you.

H E A L T H R I S K A S S E S S M E N T F O R M

Date: ________________

Member Name: ________________________________ Member I.D.#: _________________ DOB: _________________

Address: _____________________________________ City/State: ____________________ Zip: ___________________

Home Phone #: ________________________________ Cell #: _______________________ Other #: ________________

Primary Care Physician: ______________________________________________________________________________

Previous Primary Care Physician: _____________________________________ Phone #: _________________________

Other Insurance: ____________________________________________________________________________________

Are you currently enrolled in any state program (for dual enrollment purposes)?

____ YES

____ NO

Are you receiving WIC services?

____ YES

____ NO

Are immunizations up to date?

____ YES

____ NO

Are you taking any medications?

____ YES

____ NO

If yes, list medicines: 1. _________________ 2. __________________ 3. __________________ 4. _________________

Are you using any medical equipment, such as glucometer, nebulizer, wheelchair, hospital bed?

____ YES

____ NO

If yes, explain: ______________________________________________________________________________________

Are you being treated for any of the medical conditions listed?

YES

Asthma

____

Lung Disorder

____

Cancer

____

Liver Disorder

____

Heart Problems

____

Sickle Cell

____

High Blood Pressure

____

Kidney Disorder

____

Diabetes

____

Are you pregnant now?

____

Your expected delivery date: ________________________

Are you receiving services from the Florida Healthy Start Program?

____ YES

____ NO

Have you had a baby within the past 8 weeks?

____ YES

____ NO

Date: ________

Have you received services in an Emergency Room recently?

____ YES

____ NO

If yes, explain: ______________________________________________________________________________________

Have you been hospitalized in the past year?

____ YES

____ NO

If yes, explain: ______________________________________________________________________________________

Have you undergone any surgical procedures?

____ YES

____ NO

If yes, explain: ______________________________________________________________________________________

Would you like to receive information on family planning or pregnancy prevention?

____ YES

____ NO

Would you like to receive information on Teen Abstinence Program?

____ YES

____ NO

vsf md 5-5/14

vv md 92-5/14

Item #

CHVSF_559

Health Risk Assessment Form - Coventry Health Care Of Florida

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