Welcome to the CalOptima health assessment! The assessment will help you understand how you can improve your health and quality of life. After you submit your responses, you will receive an individualized health score of low, moderate or high, as well as areas of improvement and resources to help guide you to make healthier choices. If you would like to speak to a Health Coach at CalOptima, please call our Health Management Team at 1-714-246-8895. This survey is intended for CalOptima members ages 18 and older.

The information obtained in the health assessment can be used by you to better understand your health status. CalOptima nurses and health coaches may use the responses to see how we can help improve the needs of our members. You are encouraged but not required to take this health assessment. If you continue with the assessment, you agree to let CalOptima use the information for program purposes.

At CalOptima, we believe in the importance of providing services in a way that our members easily understand. If you need this survey in another language or in other formats, such as braille or large print, please call CalOptima at 1-714-246-8500 or toll-free at 1-888-587-8088. TTD/TTY users can call toll-free at 1-800-735-2929. We have staff who speak your language.

Age

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1. Age

Gender

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2. Gender

Ethnicity

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3. Ethnicity

Do you prefer speaking in a language other than English?

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4. Do you prefer speaking in a language other than English?

If you answered yes to question #4, what language do you prefer speaking in?

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5. If you answered yes to question #4, what language do you prefer speaking in?

Do you have problems with your eyes that you need special accommodations to read materials?

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6. Do you have problems with your eyes that you need special accommodations to read materials?

Do you have a problems with hearing that you need to use special equipment(s) such as hearing aids?

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7. Do you have a problems with hearing that you need to use special equipment(s) such as hearing aids?

What is your most recent weight?

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8. What is your most recent weight?

What is your height?

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9. What is your height?

Compared to others your age, would you say your health is…

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10. Compared to others your age, would you say your health is…

Do you use tobacco?

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11. Do you use tobacco?

If you answered yes to question # 11, would you like to get help with quitting?

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12. If you answered yes to question # 11, would you like to get help with quitting?

Do you have any of the following health conditions? (Mark all that apply)

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13. Do you have any of the following health conditions? (Mark all that apply)

Are you pregnant or planning to become pregnant?

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14. Are you pregnant or planning to become pregnant?

If you answered yes to question 14, what is your due date?

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15. If you answered yes to question 14, what is your due date?

If you answered yes to question 14, have you already seen a doctor for this pregnancy?

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16. If you answered yes to question 14, have you already seen a doctor for this pregnancy?

Have you had any of the following (select all that apply)?

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17. Have you had any of the following (select all that apply)?

How many days a week, on average, are you physically active (up, moving and exercising) for 30 minutes or more?

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18. How many days a week, on average, are you physically active (up, moving and exercising) for 30 minutes or more?

How important is it for you to eat healthy?

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19. How important is it for you to eat healthy?

How often is half of your plate fruits and vegetables?

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20. How often is half of your plate fruits and vegetables?

Do you read the Nutrition Facts label on grocery items?

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21. Do you read the Nutrition Facts label on grocery items?

On average, how many hours do you sleep each night?

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22. On average, how many hours do you sleep each night?

During the past year, how often did you feel stressed?

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23. During the past year, how often did you feel stressed?

If you answered a lot or sometimes to question #23, do you have a plan for coping with stress in the next 6 months?

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24. If you answered a lot or sometimes to question #23, do you have a plan for coping with stress in the next 6 months?

How often do you drink alcohol?

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25. How often do you drink alcohol?

Do you often drink 5 or more drinks in a day?

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26. Do you often drink 5 or more drinks in a day?

During the last month, did you miss work or other responsibilities because of personal or family health issues?

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27. During the last month, did you miss work or other responsibilities because of personal or family health issues?

If you answered yes to question #27, how many days have you missed work or other obligations in the last month?

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28. If you answered yes to question #27, how many days have you missed work or other obligations in the last month?

Over the past 2 weeks, how often have you had little interest or pleasure in doing things?

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29. Over the past 2 weeks, how often have you had little interest or pleasure in doing things?

Over the past 2 weeks, how often have you been feeling down, depressed or hopeless?

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30. Over the past 2 weeks, how often have you been feeling down, depressed or hopeless?

Do you want to make changes to improve your health?

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31. Do you want to make changes to improve your health?

CalOptima has programs that can help you feel more confident in your ability to manage your health. Are you interested in talking with a Health Coach from our Health Management Team?

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32. CalOptima has programs that can help you feel more confident in your ability to manage your health. Are you interested in talking with a Health Coach from our Health Management Team?

Please visit the CalOptima Interactive Self-Management Tools website for more health surveys and information. The CalOptima Health Management Team is available to help with your health needs. Please call use at 1-714-246-8895 for more information. TTD/TTY users can call toll-free at 1-800-735-2929. We have staff who speak your language. Please visit the CalOptima Interactive Self-Management Tools website for more health surveys and information.
The contents of this website are for informational purposes only. This information should not be used to diagnose or treat any illness or injury, and does not replace advice from your physician or other qualified medical personnel. The contents of this site are for your personal use, and should not be used to provide advice to others. Always seek the advice of medical personnel with any questions or concerns you have regarding any medical conditions. Never disregard medical advice from qualified personnel because of something you have read on the CalOptima website or any website link provided to you on the CalOptima website. In the event of a medical emergency, please visit your nearest emergency room or call 9-1-1. CalOptima makes no guarantee as to the accuracy or completeness of the information provided on this website. By using this website, you agree that any actions you take regarding the information provided are taken at your own risk and are not the responsibility of CalOptima.

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