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?

  • Date of Birth*
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  • This form is being completed for an:
  • Compared to others your age, how is your health?
  • How would you describe your gender?
  • Are you pregnant?
  • Do you get medical treatment for any of the following health conditions? *Choose all that apply
  • Do you get treatment for any of the following mental health conditions? *Choose all that apply
  • How many different prescriptions and overthecounter medications do you take each day?
  • In the past year, how may times have you stayed overnight as a patient in the hospital?
  • In the past 6 months, how may times have you been a patient in an Emergency Room (ER)?
  • Choose all services you have had in the past months
  • Do you need help with any of these activities? *Choose all that apply
  • Do you have the help you need with activities like bathing, eating or getting dressed?
  • How often do you feel isolated from others?
  • Over the last two weeks, how often have you been bothered by little interest or pleasure in doing things?
  • Over the last two weeks, how often have you been feeling down, depressed or hopeless?
  • In the past 12 months, did you worry that your food would run out before you got the money to buy more?
  • In the past 12 months, did he food you bought just not last and you didn't have the money to get more?
  • In the past 12 months, have you had a steady place to live?
  • In the past 12 months, have you had trouble getting utilities when needed? Examples are heat, water and electricity.
  • In the past 12 months, have you had trouble getting things you need because you didn't have a ride?
  • Do you feel physically or emotionally unsafe where you live right now? Call local police if you need immediate help. *National Domestic Violence Hotline: 1-800-799-7233 or text the word START to 88788
  • In the past 12 months, have you ben hit, slapped, kicked or physically hurt by anyone? *National Domestic Violence Hotline: 1-800-799-7233 or text the word START to 88788
  • In the past 12 months, has anyone emotionally abused you? Examples are being bullied or intimidated. *National Domestic Violence Hotline: 1-800-799-7233 or text the word START to 88788
  • Do you use tobacco products or vape?
  • Has alcohol or drug use made it hard for you to work, keep relationships or meet goals?
  • What is your race or ethnicity? *Choose all that apply
  • How would you describe your child's gender?
  • Is your child pregnant?
  • Does your child currently need or take medication prescribed by a doctor (other than vitamins)?
  • Is this because of any medical, behavioral or other health conditions?
  • Is this a condition that has lasted or is expected to last for at least 12 months?
  • Does your child need or use more medical care, mental health or educational services than is usual for most children of the same age?
  • Is this because of any medical, behavioral or other health conditions?
  • Is this a condition that has lasted or is expected to last for at least 12 months?
  • Is your child limited or unable to do the things most children of the same age can do?
  • Is this because of any medical, behavioral or other health conditions?
  • Is this a condition that has lasted or is expected to last for at least 12 months?
  • Does your child need or get special therapy, such as physical, occupational or speech therapy?
  • Is this because of any medical, behavioral or other health conditions?
  • Is this a condition that has lasted or is expected to last for at least 12 months?
  • Does your child have any kind of emotional, developmental or behavioral problem for which they need or get treatment or counseling?
  • Is this a condition that has lasted or is expected to last for at least 12 months?
  • Does your child get medical treatment for any of the following health conditions? *Choose all that apply
  • Does your child get treatment for any of the following mental health conditions? *Choose all that apply
  • Does your child have any of the follwing health conditions? *Choose all that apply
  • If your child has health problems, are you able to get the help you need caring for your child?
  • In the past year, how many times has your child stayed overnight as a patient in the hospital
  • In the past 6 months, how may times has your child been a patient in an Emergency Room?
  • Choose all services your child has had in the past 12 months
  • How often does you rchild feel overwhelmed with stress or anxiety?
  • Does your child do any of the following? *Choose all that apply
  • In the past 12 months, did you worry that your child's food would run out before you got the money to buy more?
  • In the past 12 months, did the food you bought for your child just not last, and you didn't have the money to get more?
  • In the past 12 months, has your child had a steady place to live
  • Does your child feel physically or emotionally unsafe where they live right now?
  • In the past 12 months, has your child been hit, slapped, kicked or physically hurt by someone? National Domestic Violence Hotline 1-800-799-7233 or text the word START to 88788
  • In the past 12 months, has anyone emotionally abused your child? Examples are being bullied or intimated. National Domestic Violence Hotline 1-800-799-7233 or text the word START to 88788
  • What is your child's race or ethnicity? *Choose all that apply
  • Should be Empty: