SNBC CADI/CAC/DD/BI (CCDB) Health Risk (HRA) Assessment form *Fields with asterisks are required for MMIS entry

*Client Last Name: *Client First Name: *M.I.: Click here to enter text. Click here to enter text. Click here to enter text. *Birth Date: *PMI Number UCare ID Number: Click here to enter text. Click here to enter text. Click here to enter text. Address: Phone number: Group Home contact info (if applicable) Click here to enter text. Click here to enter text. Click here to enter text. Primary Spoken Language: *Referral Date *LTCC CTY: Click here to enter text. Click here to enter a date. Click here to enter text. *Activity Type Date (date of assessment) *Activity Type Click here to enter a date. Choose an item. *COS *COR *CFR Choose an item. Choose an item. Choose an item. *Legal Rep Status – Adult Legal Rep Name: Legal Rep Contact Info: (age 18 or older) Choose an item. Click here to enter text. Click here to enter text. *Primary Diagnosis Name: Click here to enter text. *Dx Code: Click here to enter text. *Secondary Diagnosis Name: Click here to enter text. *Dx Code: Click here to enter text. *Is there a history of a DD Dx? ☐Y ☐N If so, what is the dx? Click here to enter text. *Is there a history of a MI Dx? ☐Y ☐N If so, what is the dx? Click here to enter text. *Is there a history of a BI Dx? ☐Y ☐N If so, what is the dx? Click here to enter text. *Who was present at screening? (more than one can be selected) ☐ 01 – Client ☐ 09 - NF staff ☐ 17 - Case manager ☐ 02 – Family ☐ 10 - Primary physician ☐18 - Legal counsel ☐ 03 - LTCC consultant ☐ 11 - Home care or ☐ 19 - Health plan ☐ 04 - Social worker community based service coordinator ☐ 20 – provider ☐ 05 - Public health nurse Ombudsman ☐ ☐ ☐ 06 - Hospital discharge 12 – Advocate 21 – RRS planner ☐ 13 - Conservator/Guardian ☐ 22 - Interpreter, English ☐ ☐ 23 - Interpreter, ASL ☐ 07 - Qualified mental 14 - Consulting physician retardation professional ☐ 15 - ICF/MR staff ☐ 98 – Other, please specify:

CLS 10/17 AH ☐ 08 - Qualified mental ☐16 - Services for children Click here to enter text. health professional with handicaps

Provider Information

Primary Care Clinic: Click here to enter text.

Primary Care Provider: Click here to enter text.

Address: Click here to enter text.

Phone number: Click here to enter text.

Specialty Provider: Click here to enter text.

Specialty Provider: Click here to enter text.

Specialty Provider: Click here to enter text.

Specialty Provider: Click here to enter text.

County Financial Worker: Click here to enter text.

Rule 79 Targeted CM: Click here to enter text.

*Screening & Assessment Information

*Reasons for Referral: *Current Living Situation: *Current Housing Type: Choose an item. Choose an item. Choose an item. Is living setting appropriate? ☐Y ☐N Click here to enter text. Dressing Grooming Choose an item. Choose an item. Bathing Eating Choose an item. Choose an item. Bed Mobility Transferring Choose an item. Choose an item. Walking Behavior Choose an item. Choose an item. Orientation Choose an item. Self-Preserve Communication

CLS 10/17 AH Choose an item. Choose an item. Hearing Vision Choose an item. Choose an item. Mgt. Meds/Other Treatment Insulin Dependent Choose an item. Choose an item. Money Management Transportation Choose an item. Choose an item. Have you experienced any Falls in your home or while out in the community? Choose an item. If yes, what interventions are in place? Click here to enter text.

*Assessment Results and Exit Reasons *Effective Date Choose an item. Click here to enter a date. *Program Type *CDCS *Is member on a waiver? ☐ Yes ☐ No 28- SNBC ☐ Yes ☐ No Type: Click here to enter text. Waiver CM’s contact info: Click here to enter text.

Health History

*Number of Hospitalizations in last year: Click here to enter text. Please describe: Click here to enter text.

*Number of ER Visits in last year: Click here to enter text. Please describe: Click here to enter text.

*Number of NF Stays in last 3 years: Click here to enter text. Please describe: Click here to enter text.

Risk Status Dental: Do you have a dentist? ☐ Yes ☐ No Do you have any dental concerns? ☐ Yes ☐ No  If yes, please specify: Click here to enter text.

CLS 10/17 AH Skin Assessment: Concerns present: ☐ Yes ☐ No  If yes, please specify: Click here to enter text. Have you ever experienced the following skin conditions: ☐ Rash ☐ Shingles ☐Dermatitis ☐ Diabetic Ulcer ☐Other Additional Comments: Click here to enter text.

DME: Are you currently using mobility aides? ☐ Yes ☐ No  If yes, please describe: Click here to enter text. Are you currently using safety or adaptive equipment? ☐ Yes ☐ No

 If yes, please describe: Click here to enter text.

Additional Comments: Click here to enter text.

Preventative Care

Annual Preventative Visit: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text. Dental Exam: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.

Vision Exam: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.

Hearing Exam: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.

Mammogram: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.

Cervical Cancer Screening: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.

Prostate/PSA: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.

CLS 10/17 AH Colorectal Cancer Screening: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.

Diabetic Testing: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.

Bone Density: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.

Aspirin Usage: Has a discussion occurred with provider regarding aspirin usage? ☐ Yes ☐ No ☐ N/A At ages 45-79(men) and 55-79 (women), talk with providers about benefits and risks of aspirin use. If risk factors for those under 45 years of age, speak with PCP.

Immunizations/Vaccines Influenza: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.

Pneumovac: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.

Tetanus: ☐ Yes ☐ No ☐ Unsure Last date completed: Click here to enter a date. Additional Comments: Click here to enter text.

If 18-21 years old, have you had an Annual Child/Teen Check-up? ☐ Yes ☐ No ☐N/A Date completed: Click here to enter text. Additional comments: Click here to enter text.

Home Safety

Do you feel safe within your current living arrangement? ☐ Yes ☐ No ☐ Chose not to answer  If no, list circumstances: Click here to enter text.

Do you have any safety concerns about your living arrangement? (i.e. cords, rugs, stairs) ☐ Yes ☐ No ☐ Chose not to answer  If yes, describe: Click here to enter text.

In the assessor’s opinion, does the current living arrangement appear to be safe? Can we contact them if needed? ☐ Yes ☐ No  If no, list circumstances: Click here to enter text.

Advanced Directives

CLS 10/17 AH Do you have any of the following in place? (Check all that apply) ☐ Advanced Directives ☐ Living Will☐ Durable Power of Attorney for Health Care ☐ Durable Power of Attorney for Financial ~Advance Directive discussion with member completed? ☐ Yes ☐ No  If no, explain why not? Click here to enter text.

Additional Comments: Click here to enter text.

Assessor Signature: Date: Click here to enter a date. Assessor Name and Credentials: Click here to enter text. *NPI/UMPI #: Click here to enter text.

CLS 10/17 AH