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
Email
Action ID
Fee schedule
Your Name*

First NameLast Name
Your Member ID
Your address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who is your primary care provider?
Who is your PCPI need help finding a PCP
For getting help finding your PCP, please contact Customer Service at 888-494-8769.
What is the best phone number to reach you? *
Enter your PRIMARY phone numberFormat: (000) 000-0000.
LandlineCell phone
YesNo
Which phone number for texting?
YesNo
Which phone number for personalized health information texting?
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.
Which pharmacy do you use?
Which pharmacy do you useI need help finding a pharmacy
For getting help finding your pharmacy, please contact Customer Service at 888-494-8769.
YesNo
Caregiver(s) information*
Preferred language*
No, not of Hispanic, Latino/a, or Spanish originYes, Puerto RicanYes, another Hispanic, Latino/a, or Spanish originYes, Mexican, Mexican American, Chicano/aYes, CubanI choose not to answer.
American Indian or Alaska NativeChineseJapaneseOther AsianVietnameseAsian IndianFilipinoKoreanOther Pacific IslanderWhiteBlack or African AmericanGuamanian or ChamorroNative HawaiianSamoanI choose not to answer.
WomanManNon-binaryI choose not to answerI use a different term:
Health conditions
Problems with your blood sugarHave you been told that your body holds on to too much fluid because of your heart?Problems with your heart or blood vesselsHave you had a heart attack?Have you had a stroke?Have you been told you have high blood pressure?Have you been told you have high cholesterol?Any lung problems like shortness of breath, wheezing or trouble breathing?Any problems with your kidneys or receiving dialysis?Have you ever had cancer?HIV/AIDSAny other medical conditions/problems
Yes
List organ(s):
On a scale of 0-10, what is your average daily pain level?*
Ambulating around your home (with or without assistive device)Getting in and out of bed or chairsGetting dressedPersonal hygieneFeeding yourselfUsing the toiletOther
YesNo
Falls/Balance
01 or 23+
YesNo
YesNo
Hospitals
01 or 23+
01 or 23+
Mental Health
AnxietyDepressionTrouble sleepingLittle interest or pleasure in doing thingsFeeling hopelessFeeling down
AlwaysOftenSometimesNever
DepressionAnxietyBipolar disorderSchizophreniaSubstance use disorder ("addiction")Post-traumatic stress disorder (PTSD)Intellectual or developmental disability
YesNo
I'm usually able to cope effectivelyAt times I have problems copingI often have problems coping
In general, how satisfied are you with your life?*
1 = Very dissatisfied; 5 = Very satisfied
In general, how satisfied are you with your health care services?*
1 = Very dissatisfied; 5 = Very satisfied
NoYes, I have trouble with short-term memory onlyYes, I have trouble with long-term memory onlyYes, I have trouble with both short- and long- term memory
Very hardSomewhat hardNot hard at all
I have a steady place to liveI have a steady place to live, but I am worried about losing it in the futureI do not have a steady place to live
My oven or stove does not workI have water leaksMy smoke detectors are missing, or are not workingI don't have running waterI don't have electricityOther
YesNo
AlwaysOftenSometimesNever
YesNo
YesSometimesNo
Why?
YesNo
Substance Use
YesNo
YesNo
YesNo
NeverLess than monthlyMonthlyWeeklyDaily or almost daily
YesNo
Preventive Health Screens

Is the member up to date on the following services? If they are not eligible for the screen, select "N/A"

Is the member up to date on the following? If member is not eligible for screen, select "N/A"*

Rows	Preventative Care Status	Date of Service
Mammogram within the past 2 years (women > 40 years old)
Colorectal cancer screening in the past 5 years (age 45-75 only)
Have you had a retinal eye exam in the past 12 months? (members with diabetes)
Have you had your kidney function tested in the past 12 months? (members with diabetes)
Have you had your annual flu vaccine?
Have you received the pneumonia vaccine in the last 5 years? (members > 65 years old)
Have you received the COVID-19 vaccine and boosters?
Have you had your A1C tested in the last 12 months?

What was the most recent A1C result
Yes, and my provider recommended increasing activityYes, and my provider recommended decreasing activityYes, and my provider recommended no changesNo
Very comfortableSomewhat comfortableUncomfortableDo not know how
YesNo
YesNo
YesNo
Should be Empty:

General Information

Health conditions

Falls/Balance

Hospitals

Mental Health

Substance Use

Preventive Health Screens