Care Hub HRA

Hello! This is ______ with Sona Pharmacy. I'm trying to reach __________. Your insurance has requested our help to update your health history. Do you have a few minutes to go over your health survey with me?
First Name*
Last Name*
Date of Birth*

YearMonthDay
Email*
example@example.com
Pharmacy Location
AdultChild
Responder
ExcellentVery GoodGoodFairPoorNo Response
FemaleMaleTransgender man (femaletomale)Transgender woman (maletofemaile)Genderqueer or NonconformingChoose not to answerNo ResponseOther
YesNoDoes not applyChoose not to answerNo ResponseOther
AsthmaCancerChronic PainCOPD/EmphysemaDiabetes or to much sugar in your bloodEating disorderHeart problem (irregular heartbeat, heart attach, heart surgery or heart failure)HepatitisHigh blood presuureHIV/AIDSKidney problems or dialysisObesitySickle cell diseaseNoneOther
AnxietyBipolar disorderDepressionSchizophrenia/serious mental illnessNoneChoose not to answerOther
None1-34-78 or moreNo ResponseOther
None1-23-56 or moreNo ResponseOther
None1-23 or moreNo ResponseOther
Yearly checkupColon cancer screening like a blood stool test or colonoscopyCOVID vaccineFlu shotMammography or breast examPap smear or cervical cancer screeningNone
BathingEatingGetting dressedGroomingTransfers (example; moving from bed to chair)Using the restroomWalking and standingI do not need help
I get all the help I needI need more helpNo Response
RarelySome of the tineOftenNo Response
Not all allSeveral daysmore than half the daysNearly every dayNo Response
Not all allSeveral daysmore than half the daysNearly every dayNo Response
YesNoNo Response
YesNoNo Response
Yes, I have a steady place to liveI have a place, but I am worried about losing itI do not have a place to live. I stay with others, live in a hotel, in a shelter, in a car or on the streetNo Response
YesNoNo Response
YesNoNo Response
YesNoChoose not to answerNo Response
YesNoChoose not to answerNo Response
YesNoChoose not to answerNo Response
YesNoChoose not to answerNo Response
YesNoChoose not to answerNo Response
Alaskan Native/American IndianAsianBlack/African AmericanHispanicLatinoMultiracial/MultiethnicNative Hawaiian or Pacific IslanderWhite/CaucasianChoose not to answerOther
FemaleMaleTransgender man (female-to-male)Transgender woman (male-to-female)Genderqueer or NonconformingChoose not to answerNo responseOther
YesNoDoes not applyChoose not to answerNo response
YesNoNo response
YesNoNo response
YesNoNo response
YesNoNo response
YesNoNo response
YesNoNo response
YesNoNo response
YesNoNo response
YesNoNo response
YesNoNo response
YesNoNo response
YesNoNo response
YesNoNo response
YesNoNo response
AsthmaBorn with a problem requiring surgeryCancerCerebral palsy or trouble with muscle controlCystic fibrosis or gland disorderDiabetes or too much sugar in your child's bloodEating disorderHemophilia or problems with blood clottingHIV / AIDSObesitySickle cell diseaseNoneOther
ADHDAnxietyAutism Spectrum Disorder (ASD)Bipolar or mood disorderDepressionNoneChoose not to answerOther
Vision lossHearing lossPhysical or mental disabilityLearning disabilityNone
YesNoNo response
None1-2 times3-5 times6 or more timesNo response
None1-2 times3 or more timesNo response
Yearly check-upUsual childhood immunizationsCOVID-19 vaccineEye and vision screeningHearing testLead screeningNone
Not at allRarelyWeeklyNearly every day or dailyNo response
Take street drugs or medicines not prescribes to them - for help quitting, call 1-855-780-5955Drink alcohol - for help quitting, call 1-855-780-5955Use tobacco products or vape - for help quitting, call 1-800-QUIT-NOWI do not knowNoneNo response
YesNoNo response
YesNoNo response
Yes, my child has a steady place to liveMy child has a place to live, but I am worried about losing itMy child does not have a place to live. They stay with others, live in a hotel, in a shelter, in a car or on the streetNo response
YesNoChoose not to answerNo response
YesNoChoose not to answerNo response
YesNoChoose not to answerNo response
Alaskan Native/American IndianAsianBlack/African AmericanHispanicLatinoMultiracial/MultiethnicNative Hawaiian or Pacific IslanderWhite/CaucasianChoose not to answerOther
Should be Empty: