Health Risk Survey

  • To meet Medicare requirements, Troy Medicare asks that every member complete a Health Risk Survey. Please answer the survey as completely as possible. Your responses will not affect your enrollment, benefits, or copays.

  • General Information

  • I need help finding a primary care provider

  • For getting help finding your PCP, please contact Customer Service at 888-494-8769. 

  • Format: (000) 000-0000.
  • Is this a landline or cell phone number?*
  • Is it OK to text you?
  • Is it OK to text you personalized health information, related to conditions, screenings, or medications?

  • By providing your mobile number, you agree that Troy Medicare and its authorized representatives may send you automated text messages about your health coverage and related care reminders (non-marketing). Message and data rates may apply.

    You may opt out at any time by replying STOP to any message or by contacting Troy Medicare Member Services at the number on the back of your Troy Medicare ID card. For help, reply HELP or contact Member Services.

    We will handle your protected health information in accordance with HIPAA and our Notice of Privacy Practices.

  • I need help finding a pharmacy

  • For getting help finding your pharmacy, please contact Customer Service at 888-494-8769. 

  • Do you have a caregiver, or someone who helps you with your medical needs or your daily activities?*
  • Are you Hispanic, Latino/a, or Spanish origin? Select all that apply.
  • Whatʼs your race? Select all that apply.
  • What is your gender?

  • Health conditions

  • Have you had or been treated by a doctor for any of the following?
  • In the past month, did you need any help with the following? (Select all that apply)
  • Do you have the support for everyday activities such as meal preparation, personal care, transportation, and in case of an emergency?*

  • Falls/Balance

  • In the PAST MONTH, how many times have you fallen?*
  • In the PAST 12 MONTHS, have you had any issues with your walking or balance?*
  • Have you discussed concerns regarding your balance or walking to your primary care provider?*

  • Hospitals

  • In the PAST 12 MONTHS, how many times did you visit the emergency room (ER/ED) as a patient?*
  • In the PAST 12 MONTHS, how many times did you stay overnight in the hospital as a patient?*

  • Mental Health

  • In the past month, have you noticed any of the following about yourself:
  • How often have you felt lonely or isolated from others?*
  • Do you have any of the following emotional health conditions or developmental disabilities? Select all that apply
  • Are you currently under the care of a Behavioral Health Provider?*
  • How well do you handle the stress in your life?*
  • In the PAST 12 MONTHS, have you had any problems with your memory?*
  • How hard is it for you to pay for basic needs, such as food, housing, medical care, and utilities (e.g. electric, gas, water)?*
  • What is your living situation today?*
  • Indicate any of the following problems for the place you live (Select all that apply)
  • Do you feel safe at home?*
  • In the PAST MONTH, how often were you worried your food would run out before you could buy more food?*
  • In the PAST MONTH, has a lack of reliable transportation kept you from getting to medical appointments, or other things needed for daily living?*
  • Have you had any issues taking your medications daily as prescribed by your providers?*
  • Do you have ever have problems holding your urine or with leakage?*

  • Substance Use

  • Do you use tobacco products?*
  • Are you interested in quitting tobacco products?*
  • Do you drink alcohol?*
  • How often have you had more than 4 drinks or more (women)/5 drinks or more (men) containing alcohol in one day?*
  • In the PAST 12 MONTHS, have you used drugs other than those prescribed to you?

  • Preventive Health Screens

    Is the member up to date on the following services? If they are not eligible for the screen, select "N/A"
  • Rows
  • In the PAST 12 MONTHS, have you discussed exercise with your provider?*
  • How comfortable are you scheduling a virtual appointment with your MD?
  • Would you like a copy of your care plan mailed to you?*
  • Have you checked (lately) to see if you are eligible for Medicaid?
  • Would you like assistance in applying for Medicaid?
  • Should be Empty: