McLaren Health Plan
Medicaid and Healthy Michigan Plan Member Survey

Our goal is to make sure that you feel comfortable and confident in your healthcare journey with McLaren Heath Plan. Below is a survey to help us identify any needs that you may have and to connect you with community resources or programs in your area. To achieve this, our staff may ask you questions regarding your race, ethnicity, language, sexual orientation, and gender identity. These demographic questions help us understand your background and preferences, so we can find services that are a good fit for you and offer services in your preferred language.

We care about your privacy. The Protected Health Information (PHI) we use or disclose is private. Only people who have both the need and the legal right may see your PHI.

For members under the age of 18, the survey must be filled out by a parent or legal guardian.

References:

The questions in this survey are adapted from various validated sources to ensure comprehensive and accurate assessment. For a detailed list of references and permissions, please visit our MHP Member Survey References Page.

Additionally, many of these questions are derived from The AHC Health-Related Social Needs Screening Tool developed by the Centers for Medicare & Medicaid Services (CMS). For more information, you can access the full screening tool document here.

Who is completing the survey? *

Personal Information

Member Name *

Address: *

Race, ethnicity, and language

Race (select one or more): *

Black or African American
Native Hawaiian or Other Pacific Islander
White
Asian
American Indian or Alaska Native
Some other race
Declined

Ethnicity: *

Hispanic or LatinoNot Hispanic or LatinoDeclined

Preferred Language: *

Gender identity, sexual orientation, and pronouns

Gender Identity: *

MaleFemaleUnknownChoose not to disclose

Which of the following best describes your gender? *

Male
Female
Transgender male/trans man/female-to-male (FTM)
Transgender female/trans woman/male-to-female (MTF)
Genderqueer, neither exclusively male nor female
Additional gender category or other, please specify
Choose not to disclose

Sexual Orientation: *

Pronouns: *

He/him
She/her
They/them
Choose not to disclose
Other

Health care support

Current Primary Care Physician: *

Emergency room visits:

Have you been a patient in the emergency room two or more times in the past six months? *

YesNo

Additional Support:

Do you need help finding a doctor? *

YesNo

If you have needs that make being healthy difficult, would you like someone from our team to help you with those needs? *

YesNo

Living Situation

What is your living situation today? *

I have a steady place to live
I have a place to live today, but I am worried about losing it in the future
I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)

Think about the place you live. Do you have problems with any of the following? *

CHOOSE ALL THAT APPLY

Pests such as bugs, ants, or mice
Mold
Lead paint or pipes
Lack of heat
Oven or stove not working
Smoke detectors missing or not working
Water leaks
None of the above

Food

Some people have made the following statements about their food situation. Please answer whether the statements were OFTEN, SOMETIMES, or NEVER true for you and your household in the last 12 months.

Within the past 12 months, you worried that your food would run out before you got money to buy more. *

Often trueSometimes trueNever true

Within the past 12 months, the food you bought just did not last and you did not have money to get more. *

Often trueSometimes trueNever true

Transportation

In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for daily living? *

YesNo

Utilities

In the past 12 months, has the electric, gas, oil, or water company threatened to shut off services in your home? *

YesNoAlready shut off

Safety

Because violence and abuse happens to a lot of people and affects their health we are asking the following questions.

How often does anyone, including family and friends, physically hurt you? *

Never
Rarely
Sometimes
Fairly often
Frequently

How often does anyone, including family and friends, insult or talk down to you? *

Never
Rarely
Sometimes
Fairly often
Frequently

How often does anyone, including family and friends, threaten you with harm? *

Never
Rarely
Sometimes
Fairly often
Frequently

How often does anyone, including family and friends, scream or curse at you? *

Never
Rarely
Sometimes
Fairly often
Frequently

Financial Strain

How hard is it for you to pay for the very basics like food, housing, medical care, and heating? Would you say it is: *

Very hard
Somewhat hard
Not hard at all

Employment

Do you want help finding or keeping work or a job? *

Yes, help finding work
Yes, help keeping work
I do not need or want help

Family and Community Support

If for any reason you need help with day-to-day activities such as bathing, preparing meals, shopping, managing finances, etc., do you get the help you need? *

I do not need any help
I get all the help I need
I could use a little more help
I need a lot more help

How often do you feel lonely or isolated from those around you? *

Never
Rarely
Sometimes
Often
Always

Education

Do you speak a language other than English at home? *

Yes
No

Do you want help with school or training? For example, starting or completing job training or getting a high school diploma, GED or equivalent. *

Yes
No

Physical Activity

In the last 30 days, other than the activities you did for work, on average, how many days per week did you engage in moderate exercise (like walking fast, running, jogging, dancing, swimming, biking, or other similar activities)? *

0
1
2
3
4
5
6
7

On average, how many minutes did you usually spend exercising at this level on one of those days? *

0
10
20
30
40
50
60
90
120
150 or greater

Substance Use

The next questions relate to your experience with alcohol, cigarettes, and other drugs. Some of the substances are prescribed by a doctor (like pain medications), but only count those if you have taken them for reasons or in doses other than prescribed. One question is about illicit or illegal drug use, but we only ask in order to identify community services that may be available to help you. 12

How many times in the past 12 months have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)? One drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits. *

Never
Once or Twice
Monthly
Weekly
Daily or Almost Daily

How many times in the past 12 months have you used tobacco products (like cigarettes, cigars, snuff, chew, electronic cigarettes)? *

Never
Once or Twice
Monthly
Weekly
Daily or Almost Daily

How many times in the past year have you used prescription drugs for non-medical reasons? *

Never
Once or Twice
Monthly
Weekly
Daily or Almost Daily

How often in the past year did you use marijuana? *

Never
less than monthly
monthly
weekly
daily

How many times in the past year have you used illegal drugs? *

Never
Once or Twice
Monthly
Weekly
Daily or Almost Daily

Mental Health

Over the past 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things? *

Not at all
Several days
More than half the days
Nearly every day

Feeling down, depressed, or hopeless? *

Not at all
Several days
More than half the days
Nearly every day

Stress means a situation in which a person feels tense, restless, nervous, or anxious, or is unable to sleep at night because his or her mind is troubled all the time. Do you feel this kind of stress these days? *

Not at all
A little bit
Somewhat
Quite a bit
Very much

Disabilities

Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? *

Yes
No

Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor

Yes
No

Captcha*