BadgerCare Plus Health Screening Form

Form
The BadgerCare Plus Health Screening Form is HIPAA Complaint, which means that the information is protected and will only be shared with GHC-SCW Care Management, Social Workers, Medical Providers and the GHC-SCW BadgerCare Plus Advocate.

If you have any questions or would like to complete this form over the phone, please contact GHC-SCW’s BadgerCare Plus Advocate, Holly Hippen at 608-251-4156.

We are more than happy to assist you!
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Do you have any health concerns that need attention right now?

Shortness of BreathLightheadedness/FaintingChest PainWant to Harm Yourself or Others
If you selected any of the options above, please get emergency care right away or call 911.
How would you rate your overall health?*

ExcellentVery GoodGoodFairPoor
When was the last time you had a physical or check up?*

MonthDayYear
Date
Where do you go when you need health care?*
Do you see any specialists? (Example: Heart Doctor)*

YesNo
What type of specialty care do you receive and where do you go for this care (i.e. UW Health, UnityPoint Health - Meriter, etc.)?*
Do you see any mental health or behavioral health providers?*

YesNo
In the past year, how many times have you had an overnight stay in the hospital?*
In the past year, how many times have you been to the emergency room?*
Are you currently pregnant?*

YesNo
Are you receiving prenatal care?*

YesNo
Where are you receiving prenatal care?*
If you need prenatal care, please contact Holly Hippen, the GHC-SCW BadgerCare Plus Coordinator, at (608)-662-4991.
How many medications do you take daily?*

None1-56-1011 or more
Do you have any trouble with hearing or poor vision?*

YesNo
Do you have a family member, friend or religious leader in the community you could talk to if you need help?*

YesNo
Do you have any of the following conditions?
Heart Problems*

YesNo
High Cholesterol*

YesNo
High Blood Pressure*

YesNo
Asthma*

YesNo
Lung Disease*

YesNo
Anxiety*

YesNo
Depression*

YesNo
Other Mental Health Conditions*

YesNo
Alcohol or Substance Use Disorder*

YesNo
Tobacco Use*

YesNo
Epilepsy, Parkinson's and/or Multiple Sclerosis*

YesNo
Diagnosed Learning Disability*

YesNo
Cancer*

YesNo
Diabetes*

YesNo
Obesity*

YesNo
ADHD*

YesNo
Autism*

YesNo
Chronic Pain*

YesNo
How often do you participate in any clubs or organizations? (Example: church, union, athletic, school)*

DailyWeeklyCouple times per monthCouple times per yearYearlyNever
Do you worry your food will run out before you have money to buy more?*

YesNo
In the past 12 months, has lack of transportation kept you from getting to:
Work*

YesNo
Medical Appointments*

YesNo
Pharmacy*

YesNo
Are you homeless?*

YesNo
Please check the box for any services you used in the past 6 months:

FoodShare (SNAP)Ride ShareDay Care AssistanceRental AssistanceDiaper BankWICOther
Do you have any children?*

YesNo
Are you worried about how your child is behaving or learning in school?

YesNo
Are there concerns that you feel have not been addressed in this screening or are there any topics where you would like GHC-SCW to contact you for assistance?
Should be Empty:

Form

Do you have any of the following conditions?

In the past 12 months, has lack of transportation kept you from getting to: