Confidentiality

This Health Statement is a simple tool that provides an evaluation of participants’ current health and quality of life. This tool was developed in conjunction with Johns Hopkins Bloomberg School of Public Health, whose goal is to promote equitable, effective and efficient health care around the globe.
It will take about 5 minutes to complete. All information on this form is kept confidential. Only a medical reviewer and staff authorized by your plan will review it. For your safety, please ensure all information on this form is accurate and complete. Medical conditions do not get shared with your employer.

* 1. What is your name?

* 2. What is your date of birth?

* 3. What are your last four digits of your social security number?

* 4. What is your relationship to the policyholder? 

* 7. Have you or your spouse had a flu shot in the past 12 months?

  Yes No
You
Spouse

* 9. How many times per week do you or your spouse exercise for at least 20-30 minutes?

  Never 1-2 times per week 3-4 times per week 5-6 times per week Daily
You
Spouse

* 10. Do you or your spouse have a primary care doctor that knows you personally?

  Yes No N/A
You 
Spouse

* 12. Do you and your spouse follow the request of your primary care doctor to receive preventative health care services like annual physicals, eye exams, colonoscopies, mammograms, etc.?) Select one answer per column.

  Very compliant. (receive all recommended preventative services at the recommended frequency.) Somewhat compliant. (receive most recommended preventative services at the recommended frequency.) Barely compliant. (receive only one or two recommended preventative services at an inconsistently.) Noncompliant.
(I/they do not receive preventative services.)
You
Spouse

* 13. If you or your spouse not “very compliant” with receiving preventative health care services, which reasons explain why you were unsuccessful getting the test or procedure. Select all that apply.

* 14. What health concerns have you faced in the last 12 months?

* 15. Which of the areas listed are of biggest concern to you and your health?

  Greatest Concern Second Greatest Concern Third Greatest Concern Mild Concern N/A
Anxiety/Depression
Asthma
Arthritis
Back pain
Diabetes
Financial stress
Heart conditions
High blood pressure
Communication/Listening Skills
High cholesterol
Migraines
Overweight
Smoking

* 16. How compliant are you and your spouse with taking your medications as prescribed? 

  Very compliant. (receive all recommended preventative services at the recommended frequency.) Somewhat compliant. (receive most recommended preventative services as
recommended.)
Barely compliant. (receive only one or two recommended preventative services inconsistently.)  Noncompliant.
(I/they do not receive preventative services.)
You
Spouse

* 17. If you or your spouse were not “very compliant” with your medications, Why not? ( If you answered "Very Compliant" in the previous question, please proceed to question #18).

* 18. Are there other things your doctor has suggested that  you or your spouse have been less than very complaint?

* 19. If yes, please specify?

* 20. Are you or your spouse overweight?

  Yes No
You
Spouse

* 21. Are you or your spouse interested in losing weight?

  Yes No
You
Spouse

* 22. If yes, what are your primary motivations to reach your weight goal?

* 23. What services would assist you in maintaining long term healthy weight and good nutrition?

* 24. There are numerous services that could be offered as part of the wellness program. If offered, which would you participate in:

  Strongly Agree Agree Neutral Disagree Strongly Disagree
How to start an exercise program
Back safety
Financial management
Accepting change
Parenting Difficulties
Medical financial planning
Heart disease prevention
Healthy cooking
Healthy grocery store shopping
Healthy foods at work
Regular blood pressure checks
Overweight
Health coaching
Smoking Cessation programs
Time management programs
Flu shots
Have you felt downhearted or blue in the past 6 months?
Has your physical or emotional health affected your social activities?
Has your physical or emotional health affected your effectiveness at work?
Do you believe your employer is concerned about your personal wellbeing?
Are you proud of the work you do?
Working in this organization is good for my health.
My supervisor, or someone at work, cares about me as a person.
My organization consistently provides opportunities for growth and development.
I trust that my organization cares about me.
I trust my supervisor and/or senior leadership.
My supervisor and/or senior leadership trusts me.

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