Member materials and tools

Child health assessment

Magellan Complete Care, your health plan, wants to help you or your child feel better and enjoy a healthy life.

These health questions will help us to better understand how you or your child is feeling. It will help us know what services and resources you will need to stay healthy and feel well. The questions will take you about 15 minutes to complete. If you do not understand any of the questions or need help with the form, please call us at 800-327-8613.

As your or your child’s health plan it is key that we work very closely with your doctors. We make sure you get the care you need. If you give us the OK, we can share this information with your or your child’s doctors. This will make sure you your child gets good care and help your (your child’s) doctors talk to each other. Without your OK, we will not share any information with anyone.

 

Fields marked with an * are required. 

 

Please fill out the following form.
Do you agree for us to share your answers with your doctors?
About You/Your Child
Sex *
Other Insurance
Do you/your child have reliable transportation to appointments? *
Where do you (or your child) currently live? *
Who do you (or your child) live with? *
Do you/(Does your child) have a caregiver or someone we can contact if we can't reach you?
If yes, do you give Magellan Complete Care permission to give information to this person?
About/Your Child's Physical Health
Do you have any concerns about your (your child's) overall health? *
In the past 4 weeks, how many days did you (your child) miss from work or school because of problems with your/their physical or mental health? (Please include only days missed for your own/your child's health, not someone else's health.)
During the past 7 days, how much did your (the child's) physical or mental health affect you/your child being able to do things at work or at school?
Do you (your child) have any of the following?
Are you (your child) currently pregnant? *
About Care You/Your Child Receives
How many times have you (your child) been seen in the Emergency Room in the last 3 months? *
How many times have you (your child) stayed overnight in a hospital room in the past 3 months? *
Have you (your child) had any major falls or injuries in the last 6 months? *
Do you (your child) use any medical equipment? *
Do you (the child) get assistance with Activities of Daily Living such as dressing, feeding, bathing?
What number best describes how much, during the past week, pain has affected with your (your child's) general activity?
How many prescriptions/medications (other than vitamins) do you (does your child) take? *
Write "N/A" if you do not currently have a primary care provider
Write "N/A"if you do not currently have a behavioral health provider
Write "N/A" if you do not currently have a dentist
Please fill out the following form.
Have you/(Has your child) had any of the following health screenings in last 12 months? Please document the date of the last exam for each of the items that apply.
Routine Physical Exam (CHCUP
Tetanus Vaccination
Dental Exam
HPV Vaccination
Vaccination Series Complete?
Meningococcal Vaccination
About Your/Your Child's Lifestyle
How many meals do you/(your child) eat on a regular day? *
How often do you (does your child) eat fast food, processed foods (such as chicken nuggets, hot dogs, bologna) or fried foods? *
How would you describe your (the child’s) physical activity/exercise level? *
On average how many hours of sleep do you (your child) get per night? *
Do you (your child) currently use tobacco products? *
Are there any substance use concerns for you (your child)? *
About Your/Your Child's Emotional Health

Over the past 2 weeks, how often have you (has your child) been bothered by any of the following problems?

Little interest or pleasure in doing things? *
Feeling down, depressed or hopeless? *
About Your/Your Child's Future Health
How important is it to you/your child to make a change to your health right now? *
How confident are you/your child about making a change to your health right now? *
How ready are you/your child to make a change to your health right now? *