DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-10180 (07/08)
STATE OF WISCONSIN Effective 2/1/08
NEW ENROLLEE HEALTH NEEDS ASSESSMENT (NEHNA) SURVEY - ENROLLEE VERSION
Name (Last, First, MI) Address City Medicaid Number State Zip Code Birth Date Telephone Number
You may choose to not answer any or all of the questions. The information you give will only be used to help your health plan meet your health care needs. Your answers will be shared only with your health plan and health care providers.
Question Yes No Not Sure Additional Answer
1. Primary language used in your family? 2. Are there other phone numbers that can be used to reach you? If, yes, please list (include area code). 3. Are there other people we can contact if we need to reach you? If yes, please list the name and phone number of these people. 4. Will you be moving from your present address anytime in the next six months? 5. Have you or your child(ren) seen a doctor or other medical provider for any illness or injury in the past year? 6. Do you have a doctor or medical provider that you consider your regular or family doctor? 7. Do you have children under age 21 in your home? If no, skip to #8. a. Do you have any concerns about their growth or health? b. Have all of these children seen a doctor in the past year? c Are any of these children in the Birth to 3 Program?
English Spanish Hmong Other Read ( ) ( ) Best time to call AM Name Phone ( ) Name Phone ( ) New address, if known. If yes, who? If yes, doctor's name Clinic's name If yes, what are their ages? If yes, who? If no, who hasn't? If yes, who? What? Why?
Russian Speak PM
NEW ENROLLEE HEALTH NEEDS ASSESSMENT (NEHNA) SURVEY - ENROLLEE VERSION F-10180 (07/08)
Question 8. Have you or your child(ren) been in the hospital or had surgery in the past year? a. Is any surgery planned? 9. Are you or any member of your family pregnant? 10. Do you or any member of your family need prescription medicine for any of the following medical conditions?
Not Sure If yes, who? If yes, who? If yes, who? Estimated due date? If yes:
More information For what? For what?
Asthma ("attacks" of difficult breathing) Diabetes (high or low blood sugar) High blood pressure Heart problems Disabilities (blind, deaf, wheelchair bound, etc.) Mental health treatment Alcohol or other drug abuse Pain If YES: Do any of these conditions limit or prevent any routine daily activities? Have any of these conditions lasted, or are expected to last at least 12 months? 11. Do you or a family member need regular medical care for any other health problem? 12. Will you need assistance with transportation to health care appointments? 13. Do you or a member of your family smoke cigarettes or use other tobacco products?
Who? Who? Who? Who? Who? Who? Who? Who? Other information?
If yes, who?
If yes, who?
a. If yes, does this person want help quitting? If yes, who? For questions, call: 800 291-2002. Send the completed form to: Wisconsin HMO Enrollment Specialist, P.O. Box 510408, Milwaukee WI 53203-9962.