UCare Connect Health Risk Assessment
*Fields with asterisks are required for MMIS entry
*Client Last Name:
/*Client First Name:
/*M.I.:
Click here to enter text. / Click here to enter text. / Click here to enter text.*Birth Date:
/*PMI Number
/ UCare ID Number:Click here to enter text. / Click here to enter text. / Click here to enter text.
Address:
/ Phone number: /Sex:
Click here to enter text. /Click here to enter text.
/ ☐Male ☐FemalePrimary Spoken Language:
/*Referral Date
/ *LTCC CTY:Click here to enter text. /
Click here to enter a date.
/ Click here to enter text.*Activity Type Date (date of assessment)
/*Activity Type
Click here to enter a date.
/Choose an item.
*COS
/*COR
/*CFR
Choose an item. / Choose an item. / Choose an item.*Legal Rep Status – Adult (age 18 or older)
/ Legal Rep Name: / Legal Rep Contact Info:Choose an item. / Click here to enter text. / Click here to enter text.
*Primary Diagnosis Name:
/ Click here to enter text. / *Dx Code: Click here to enter text.*Secondary Diagnosis Name: / Click here to enter text. / *Dx Code: Click here to enter text.
*Is there a history of a DD Dx? ☐Y ☐N If so, what is the dx? Click here to enter text.
*Is there a history of a MI Dx? ☐Y ☐N If so, what is the dx? Click here to enter text.
*Is there a history of a BI Dx? ☐Y ☐N If so, what is the dx? Click here to enter text.
*Who was present at screening? (more than one can be selected)
☐ 01 – Client ☐ 02 – Family ☐ 03 - LTCC consultant
☐ 04 - Social worker ☐ 05 - Public health nurse ☐ 06 - Hospital discharge planner
☐ 07 - Qualified mental retardation professional ☐ 08 - Qualified mental health professional / ☐ 09 - NF staff ☐ 10 - Primary physician ☐ 11 - Home care or community based service provider
☐ 12 – Advocate ☐ 13 - Conservator/Guardian ☐ 14 - Consulting physician ☐ 15 - ICF/MR staff ☐16 - Services for children with handicaps / ☐ 17 - Case manager ☐18 - Legal counsel ☐ 19 - Health plan coordinator ☐ 20 – Ombudsman ☐ 21 – RRS ☐ 22 - Interpreter, English ☐ 23 - Interpreter, ASL
☐ 98 – Other, please specify: Click here to enter text.
Provider Information
Primary Care Clinic: / Click here to enter text.Primary Care Provider: / Click here to enter text.
Address: / Click here to enter text.
Phone number: / Click here to enter text.
Specialty Provider: / Click here to enter text.
Specialty Provider: / Click here to enter text.
Specialty Provider: / Click here to enter text.
Specialty Provider: / Click here to enter text.
County Financial Worker: / Click here to enter text.
Rule 79 Targeted CM: / Click here to enter text.
*Screening & Assessment Information
1. *Reasons for Referral:
/2. *Current Living Situation:
/3. *Current Housing Type:
Choose an item. / Choose an item. / Choose an item.Notes: Click here to enter text.
4. Dressing
/5. Grooming
Choose an item. / Choose an item.6. Bathing
/7. Eating
Choose an item. / Choose an item.8. Bed Mobility
/9. Transferring
Choose an item. / Choose an item.10. Walking
/11. Behavior
Choose an item. / Choose an item.12. Toileting
/13. Orientation
Choose an item. / Choose an item.14. Self-Preserve
/15. Communication
Choose an item. / Choose an item.16. Hearing
/17. Vision
Choose an item. / Choose an item.18. Mgt. Meds/Other Treatment
/19. Insulin Dependent
Choose an item. / Choose an item.20. Money Management
/21. Transportation
Choose an item. / Choose an item.22. Telephone Answer & Use
/23. Shopping (food, other)
Choose an item. / Choose an item.24. Meal Preparation/Clean Up
/25. Laundry (in/out; run washer/dryer)
Choose an item. / Choose an item.26. Light Housekeeping/Cleaning (dusting/sweeping)
/27. Heavy Housekeeping (yard work, empty garbage)
Choose an item. / Choose an item.28. Have you experienced any Falls in your home or while out in the community?
Choose an item.Note levels of assistance required for above ADL’s/IADL’s if applicable: Click here to enter text. If a member identifies a need and is not getting help currently, send to CC.
29. *Assessment Results and Exit Reasons
/30. *Effective Date
Choose an item. / Click here to enter a date.31. *Program Type
/32.*CDCS
/33. *Is member on a waiver? ☐ Yes ☐ No
28- SNBC / ☐ Yes ☐ No / If so, what type? Click here to enter text.Health History
34. *Number of Hospitalizations in last year: Click here to enter text.Please describe: Click here to enter text.
35. *Number of ER Visits in last year: Click here to enter text.
Please describe: Click here to enter text.
36. *Number of NF Stays in last 3 years: Click here to enter text.
Please describe: Click here to enter text.
37. Current weight: Click here to enter text.
/ 38. Current height: Click here to enter text.39. Do you have any of the following health conditions? Check all that apply.
Neurological:☐CVA ☐ Seizures ☐ Parkinson’s
☐Quadriplegic/Paraplegic/Spinal cord injury
☐ Other: Click here to enter text. / Sexually active?
☐ Yes ☐ No ☐ Chooses not to answer
If yes, are there any family planning needs identified? ☐ Yes ☐ No
Cardiovascular:
☐ CHF ☐ HTN ☐ Angina ☐ Other: Click here to enter text. / Pregnant
☐ Yes ☐ No ☐ NA
· If yes, how far along are you? Click here to enter text.
· If yes, are you receiving prenatal care? ☐ Yes ☐ No
If no, why not? Click here to enter text.
Respiratory:
☐ COPD ☐ Asthma ☐ Other: Click here to enter text.
Gastrointestinal:
☐ Stomach ☐ Ulcers ☐ Hepatitis ☐ Other: Click here to enter text.
Genitourinary:
☐ Dialysis ☐ Bladder/Kidney Infection ☐ Other: Click here to enter text. / Cancer:
☐ Yes ☐ No
· If yes, have you received: chemotherapy? ☐ Yes ☐No radiation? ☐Yes ☐ No
Please specify type: Click here to enter text.
Endocrine:
☐ Diabetes ☐ Thyroid ☐ Other: Click here to enter text.
Blood and/or Immune Disorders:
☐ Anemia ☐Other: Click here to enter text.
/ Dental:Do you have a dentist? ☐ Yes ☐ No
Do you have any dental concerns?
☐ Yes ☐ No
· If yes, please specify: Click here to enter text.
Musculoskeletal:
☐ MS ☐ Arthritis ☐ Rheumatoid Arthritis ☐ Amputation ☐ Fractures ☐ Other: Click here to enter text.
Gynecological:
☐ Reproductive System problems or concerns:
· Please describe: Click here to enter text. / Skin Assessment:
Concerns present: ☐ Yes ☐ No
· If yes, please specify: Click here to enter text.
Have you ever experienced the following skin conditions: ☐ Rash ☐ Shingles ☐Dermatitis ☐ Diabetic Ulcer ☐Other
Additional Comments: Click here to enter text.
Other:
HIV/AIDS: ☐ Yes ☐No
STD(s): ☐ Yes ☐No
If yes, please specify: Click here to enter text.
Physical Activity:
Are you physically active? ☐ Yes ☐ No
Would you like to be more active? ☐ Yes ☐ No
~Discuss UCare fitness options (i.e. Silver Sneakers; Wellness Kit; Wellness tools)
Additional Comments: Click here to enter text.
DME:
Are you currently using mobility aides? ☐ Yes ☐ No
· If yes, please describe: Click here to enter text.
Are you currently using safety or adaptive equipment? ☐ Yes ☐ No· If yes, please describe: Click here to enter text.
Additional Comments: Click here to enter text.
Mobility:
What type(s) of transportation do you use to get to medical appointments?Choose an item.
· If other, please specify: Click here to enter text.
Additional Comments: Click here to enter text.
Spiritual/Cultural:
Do you have a spiritual/cultural support system? ☐ Yes ☐ No
· If yes, please describe: Click here to enter text.
Additional Comments: Click here to enter text.
Pain: Do you have a current or history of acute and/or chronic pain? ☐ Yes ☐ No
· If yes, duration of acute or chronic pain? Choose an item.· If yes, please rate your pain on a scale of 1-10? (1 being lowest, 10 being highest or NA) Choose an item.
Source of Pain, please describe: Click here to enter text.Pain Alleviation: Choose an item.
· If other, please specify: Click here to enter text.
Does your pain interfere with your daily activities? ☐ Yes ☐ No ☐ NA
· If yes, please explain: Click here to enter text.Additional Comments: Click here to enter text.
40. Preventative Care
Annual Preventative Visit: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.Dental Exam: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.
Vision Exam: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.
Hearing Exam: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.
Mammogram: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date.
Additional Comments: Click here to enter text.
Cervical Cancer Screening: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.
Prostate/PSA: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date.
Additional Comments: Click here to enter text.
Colorectal Cancer Screening: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.
Diabetic Testing: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.
Bone Density: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.
Aspirin Usage: Has a discussion occurred with provider regarding aspirin usage?
☐ Yes ☐ No ☐ N/A At ages 45-79(men) and 55-79 (women), talk with providers about benefits and risks of aspirin use. If risk factors for those under 45 years of age, speak with PCP.
41. Immunizations/Vaccines
Influenza: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date.
Additional Comments: Click here to enter text.
Pneumovac: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date.
Additional Comments: Click here to enter text.
Tetanus: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date.
Additional Comments: Click here to enter text.
If 18-21 years old, have you had an Annual Child/Teen Check-up? ☐ Yes ☐ No ☐N/A
Date completed: Click here to enter text. Additional comments: Click here to enter text.
Mental Health History
42. Do you have any of the following health conditions? Check all that apply.Anxiety ☐ Yes ☐ No ☐ Chose not to answer
Depression ☐ Yes ☐ No ☐ Chose not to answer
Mania ☐ Yes ☐ No ☐ Chose not to answer
Phobias ☐ Yes ☐ No ☐ Chose not to answer / Delusions ☐ Yes ☐ No ☐ Chose not to answer
Obsessions/Compulsions ☐ Yes ☐ No
☐ Chose not to answer
Hallucinations ☐ Yes ☐ No ☐ Chose not to answer
o If yes, ☐Auditory ☐ Visual ☐ Both
43. *Do you have a MH-TCM? ☐ Yes ☐ No
~If no, are they appropriate for a referral to TCM? ☐ Yes ☐ No
44. Have you ever been diagnosed with a mental illness? ☐ Yes ☐ No ☐ Chose not to answer
· If yes, diagnosis? Click here to enter text.
· If yes, do you feel your mental health is under control? ☐ Yes ☐ No ☐ Chose not to answer
45. Are you receiving MH services currently? ☐ Yes ☐ No ☐ Chose not to answer
· If yes, please describe: Click here to enter text.
If no, would you like assistance finding a provider? ☐ Yes ☐ No ☐ Chose not to answer
46. Have you seen a specialist about symptoms/diagnosis? (i.e. Psychiatrist)
☐ Yes ☐ No
· If yes, what was done? Click here to enter text.
o Did it help? ☐ Yes ☐ No
If no, would you like help? Click here to enter text.
47. Have you ever been hospitalized or committed due to related mental health issue(s)?
☐ Yes ☐ No ☐ Chose not to answer
· If yes, how many times?
· If yes, for what reason were you hospitalized or committed: Click here to enter text. ☐ Chose not to answer
· Was it helpful? ☐ Yes ☐ No ☐ Chose not to answer
· If no, in their opinion, why or why not? Click here to enter text.
Additional Comments: (i.e. dates of Tx/where Tx occurred/for what reasons): Click here to enter text.
Substance Abuse
48. Currently smokes/uses tobacco? ☐ Yes ☐ No ☐ Chose not to answer49. Do you have any chemical health diagnoses or concerns? ☐ Yes ☐ No ☐ Chose not to answer
· If yes, please explain: Click here to enter text.
~If yes, proceed to CAGE assessment or review previous CAGE assessment
(The CAGE Assessment is a validated tool used in order to indicate whether a person feels they have a problem with drugs or alcohol.)
CAGE Assessment:
§ Have you ever felt you should cut down on your substance use? ☐ Yes ☐ No ☐ Chose not to answer
§ Has anyone ever been concerned with your substance usage or thought your usage may be a problem? ☐ Yes ☐ No ☐ Chose not to answer
§ Have you ever been annoyed by other people’s concerns over your substance use? ☐ Yes ☐ No ☐ Chose not to answer
§ Have you ever felt bad or guilty about your substance usage? ☐ Yes ☐ No ☐ Chose not to answer
§ When using substances, what time of day do you usually start use? Click here to enter text. ☐ Chose not to answer
§ Have you ever used substances first thing in the morning to steady your nerves and/or get rid of hangovers (“Eye Opener”)? ☐ Yes ☐ No ☐ Chose not to answer
Medications (Prescribed and Over-the-counter)