Initial Health Assessment (IHA)

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Renew Your Enrollment in the One Medical Fee Waiver Program

In order to keep your enrollment in the One Medical Fee Waiver Program current, you must complete this Health Assessment form annually. Failure to complete this form annually may result in the cancellation of your fee waiver.

If you have not enrolled in the One Medical Fee Waiver Program yet, please Enroll Here.

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Complete your Initial Health Assessment (IHA) here.

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Name*

Prefix First Middle Last Suffix

Member ID*

Not a member yet? Enter "NEW"

What is your current height?*

Measurements in Ft/In

What is your current weight?*

Weight in the lbs

Date of Birth*

MM slash DD slash YYYY

MM/DD/YYYY

In general, would you say your health is:*

Poor

Fair

Good

Very Good

Excellent

When was the last time you saw your primary care doctor?*

Less than 6 months ago

6-12 months ago

More than a year ago

Have you had 3 or more emergency room (ER) visits in the last 12 months?*

Yes

Have you been hospitalized 2 or more times in the past 12 months?*

Yes

In the past 4 weeks, have you been feeling down, hopeless, or have little interest in doing things?*

Yes

Do you need help to get around inside or outside the home?*

Yes

Do you use a cane, wheelchair, or walker?*

Yes

Have you fallen 2 or more times in the last 12 months?*

Yes

Do you currently drink wine, beer, or other alcoholic beverages on a daily basis?*

Yes

Do you smoke cigarettes, use tobacco, or any nicotine products currently or in the last 6 months?*

Yes

What health conditions do you have currently, or had in the past?*

Allergies

Asthma

Bowel and Gastrointestinal Conditions

Cancer

Colds and Flu

COPD (Chronic Obstructive Pulmonary Disease)

Diabetes

Disease and Disease Prevention

Down Syndrome, Autism and Developmental Delays

Epilepsy

Fatigue and Sleep

Heart Health and Stroke

Hepatitis

HIV

Infectious Diseases

Joints and Spinal Conditions

Kidneys

Lungs and Respiratory Conditions

Multiple Sclerosis (MS)

Obesity

Skin, Nails and Rashes

Thyroid

None

Other

What other health conditions do you currently have, or had in the past?*

Have you ever had surgery or any medical procedures?*

Yes

Please list all of your prior surgeries and/or medical procedures:

Type of surgery or medical procedure	Date Performed	Actions

There are no Surgeries/Medical Procedures.

Maximum number of surgeries/medical procedures reached.

Are you currently taking any medications or supplements?*

Yes

Please list all of your current medication(s) and/or supplement(s):

Name of Medication	Dosage	Frequency	Actions

There are no Medications.

Maximum number of medications reached.

Are you filling this out for yourself or a dependent on your health insurance plan?*

Myself

My Dependent

Consent*

I hereby certify that, to the best of my knowledge, the provided information is true and accurate.

Name of person filling out, and signing this form*

First Last

Best Email*

An email confirmation of your submission will be sent to this email address.

Signature*

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Date

MM slash DD slash YYYY

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