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Overall Health Assessment

Thank you for visiting the SummaCare Overall Health Assessment. This information is being gathered so we can ensure we provide the highest quality services to our new members. The information collected on this form will be provided to our Health Services Management Department so they can reach out with any valuable programs to support our members with managing chronic health conditions. Completion of this information is voluntary.

Chronic Conditions

Do you have diabetes?
Do you have heart failure?
Do you have COPD?
Do you have asthma?
Do you have another chronic condition?

Other Questions

Do you take more than five prescription medications?
Have you been to the hospital in the last six months?
Do you need transportation assistance getting to the doctor?
Have you fallen in the last 3 months or have walking or balance trouble?
Do you have trouble with forgetfulness, depression, mood swings, or confusion?
Do you live alone with little or no family support?

Your Information

For Agent Use Only