Health Risk Assessment

Let's get started

This assessment helps us understand your health needs so we can connect you with the right care and services. It takes about 5–10 minutes. You can stop at any time — your answers are saved on this device until you submit.

How is this assessment being completed?

Assessment type

Is someone helping complete this form? The member must give permission for another person to complete it.

Name of the person assisting, and their relationship to the member

About you

Basic information so we can match this assessment to your record.

Full name First, middle, last

Medicaid ID

Date of birth

Street address

City

State

ZIP

Home phone

Cell phone

Other phone Optional

Emergency contact name and phone

Demographics verified?

Communication & preferences

Help us communicate with you in the way that works best.

Question 1

Do you have a language need other than English?

What language do you prefer?

Do you need translation services?

Question 2

Do you have any special preferences we should be aware of? Select all that apply.

Please describe

Your health today

Tell us about your current health so we understand what matters most.

Question 3

What is your main health concern right now?

Question 4

Do you have any current or past physical and/or behavioral health conditions or diagnoses? Select all that apply.

Please describe

Question 5 · Adults only

Compared to others your age, would you say your health is…

Recent care & medications

A few questions about appointments, hospital visits, and medicines.

Question 6

Do you have any pending physical health procedures or behavioral health appointments?

Date of most recent physical exam or medical appointment Approximate is fine.

Question 7

Have you visited the Emergency Room in the past 6 months?

How many visits?

Date(s) of ER visit(s)

Reason for visit(s)

Question 8

Have you stayed overnight in the hospital in the past 6 months?

How many times?

Were you readmitted within 30 days of discharge?

Question 9

How many medicines are you currently taking?

Home & daily living

Understanding your living situation helps us find the right support.

Question 10

What is your current living situation?

Please describe

Question 11

Do you need assistance with any of the following? Select all that apply.

Please describe

Is your need for assistance being met today?

Planning & services

Almost done — a few questions about services and future care planning.

Question 12

Do you need, or are you interested in, Long-Term Care services?

Question 13

Do you have a living will or an advance directive in place? An advance directive is a form that lets your loved ones know your health care choices if you are too sick to make them yourself. Select all that apply.

Could we send you more information?

Question 14

Are you interested in receiving Care Coordination services? Care Coordination connects you with a personal contact who helps arrange care, appointments, and services.

Member information checklist To be confirmed by the assessor: the following was shared with the member during this HRA.

Review your answers

Check everything over before submitting. Tap Edit on any section to make changes.

Assessment complete

Thank you. Your responses have been recorded.

View submission payload (developer)

Prototype note: in production this payload would POST to your intake endpoint (REST API, FHIR QuestionnaireResponse, or a webhook) instead of displaying here. All data in this demo stays in your browser.