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.

Your answers to this survey are private and optional. You can skip any question you don't want to answer. Your answers will not change your health care coverage.

If you have any questions or would like to complete this form over the phone, please contact GHC-SCW’s BadgerCare Plus Advocate, Layla Syverson at 608-662-4991.

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.Format: (000) 000-0000.
Email
example@example.com
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.
MaleChoose not to discloseFemaleIntersexNot recorded on birth certificateUncertainUnknownX
Choose not to discloseMaleGenderqueerNon-binaryFemaleTransgender FemaleTransgender MaleOther
She/her/hersHe/him/hisThey/them/theirsYour nameDecline to AnswerUnknownNot Listed
Black or African AmericanNative Hawaiian or other pacific islanderWhiteAsianAmerican Indian or Alaska NativeSome other raceDecline to answer.
Hispanic or LatinoNot Hispanic or LatinoDecline to answer.
ExcellentVery GoodGoodFairPoor
When was the last time you had a physical or check up?

MonthDayYear
Date
When was the last time you went to the dentist?
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.)?
YesNo
YesNo
YesNo
Where are you receiving prenatal care?
If you need prenatal care, please contact Layla Syverson, the GHC-SCW BadgerCare Plus Coordinator, at (608)-662-4991.
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?
None1-56-1011 or more
NeverRarelySometimesOftenAlways
Do you have any of the following conditions?
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Do you have any other immediate or long-term concerns?
I don't need any helpI get all the help I needI could use a little more helpI need a lot more help
NeverSometimesOftenAlwaysDoes not apply
YesNoDecline to Answer
Social Determinants of Health
Financial Resource Strain:
Not hard at allNot very hardSomewhat hardHardVery hardDecline to answer
Food Insecurity:
Never trueSometimes trueOften trueDecline to answer
Never trueSometimes trueOften trueDecline to answer
Housing:
YesNoDecline to answer
1 or fewer2 or fewerDecline to answer
YesNoDecline to answer
Transportation:
YesNoDecline to answer
YesNo
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?

Social Determinants of Health

Financial Resource Strain:

Food Insecurity:

Housing:

Transportation: