True Health New Mexico Healthy Check Up

Welcome

Welcome to True Health New Mexico. We would like to work with you to find out your specific health needs and guide you to as many True Health New Mexico health services and providers as you may need. We need your help in setting the plan for your health.

We would like to work with you to find out your specific health needs and guide you to as many True Health New Mexico health services and providers you may need. We need your help in setting the plan for your health.

¿Necesita usted completar esta encuesta en español? Haga clic aquí. https://www.research.net/r/THNMHealthyCheckUpSpanish

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* 1. Demographics (required)

Name

Email Address

Phone Number

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* 2. Date of Birth (required)

Date

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* 3. Subscriber ID

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* 4. Do you have a primary care provider (PCP)?

Yes

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* 5. If you marked no, can we call you to help you find a primary care provider (PCP)?

Yes

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* 6. Have you been seen by any of the following types of providers within the last 12 months?

Specialist

Home Health Provider

Provider(s) Name(s)

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* 7. How would you rate your health?

Excellent

Good

Average

Poor

Very Poor

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* 8. Have you been diagnosed with any of the following illnesses?

Asthma

Chronic Obstructive Pulmonary Disease (COPD)

Congestive Heart Failure

Coronary Artery Disease (chest pain, heart attack)

Diabetes

Other (please specify)

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* 9. Are you taking any medications for your chronic illness?

Yes

If yes, please list medication(s):

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* 10. Have you stayed overnight in a hospital in the last six months?

Yes

If yes, what was the reason?

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* 11. Have you been seen in an emergency room in the last six months?

Yes

If yes, what was the reason?

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* 12. If you are 50 - 75 years of age, have you been screened for colon cancer by colonoscopy, flexible sigmoidoscopy, fecal occult blood testing or barium enema in the last 10 years?

Yes

N/A

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* 13. WOMEN ONLY: If you are a female age 21-64, have you had a cervical cancer screening test (Pap smear) in the last 3 years?

Yes

N/A

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* 14. WOMEN ONLY: If you are a female age 50-74, have you had a breast cancer screening exam (Mammogram) in the last 2 years?

Yes

N/A

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* 15. Do you have any of the following behavioral health conditions?

Depression

Anxiety

Bipolar Disorder

PTSD

Schizophrenia

Other (please specify)

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* 16. Over the past 12 months, has poor physical or mental health kept you from doing your usual activities, your work, or recreation?

Yes

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* 17. Over the last month, did you ever feel that your difficulties were piling up so high that you could not overcome them?

Yes

If you answered yes to question 15, click on the link below to access the M3 Behavioral Health Assessment.

https://whatsmym3.com/

Thank you for taking time to complete the Healthy Check-Up Interview! At True Health New Mexico, we believe in empowering our members to take charge of and improve their health. On our Staying Healthy page, you can find community resources and support groups, plus get access to A.D.A.M., our complete source of health and wellness information, interactive features, self-management tools, assessments, and content. You can find all of A.D.A.M.’s tools and resources by visiting Connecting You to Wellness.