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McLaren Health Plan: Your Choice for Michigan Health Insurance|McLaren Health Plan|Health & Wellness|Staying In Touch Program

Staying In Touch Program: Personalized Care with McLaren Health Plan

Health & Wellness

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Staying In Touch program

The Staying In Touch program connects our members with their own personal nurse who will help you with all of your health care needs. By taking a moment to fill out and return this survey, your confidential responses will help us get In Touch with you and determine if you would benefit from this program.

The information provided in this survey is confidential and subject to your privacy rights.

McLaren Health Plan Staying in Touch Survey

Please rate your experience

Welcome to McLaren Health Plan! The Staying In Touch program connects our members with their own personal nurse who will help you with all of your health care needs. By taking a moment to fill out and return this survey, your confidential responses will help us get In Touch with you and determine if you would benefit from this program.

The information provided in this survey is confidential and subject to your privacy rights.

Please fill in your name and contract number (found on your card) below. As you read through the questions, please check the box that most accurately describes your condition.

Member Name:

Contract Number:

Age:

We want to make sure that all our members get the best care possible. Although you have the option not to answer questions about ethnicity or race, this information helps us review the treatment that members receive and make sure that everyone gets the highest quality of care. (You may select more than one option.)

Are you Spanish/Hispanic/Latino?

No

Yes

Not sure

Refused

What is your race?

White

Black

American Indian or Alaska Native

Asian

Other

Native Hawaiian or Pacific Islander

What is your gender?

Male

Female

1. How would you describe your general health?

Excellent

Good

Fair

Poor

2. Have you had an annual physical exam in the last year?

Yes

No

3. Has a healthcare professional told you that you have any of these conditions?
(If Yes, check the box, if no, leave blank

Heart Problems	High Blood Pressure
Asthma	Diabetes
Stomach Problems or Ulcers	Kidney Disease
Chronic Pain	Obesity
Depression	Other Health History

4. Please explain the current treatments for the conditions indicated above:

5. Are you on three or more medications - prescription or over-the-counter?

Yes

No

6a. Please list your height:

6b. Your weight in lbs:

SPECIAL NEEDS

7. Do you have a vision impairment that requires special reading materials?

Yes

No

8. Do you have a hearing impairment that requires special equipment?

Yes

No

9. Is English your primary language?

Yes

No

9a. If not, what language do you prefer to speak?

HEALTHY LIFESTYLES

10. Do you eat a healthy diet that includes whole grain bread, pasta, beans, nuts, fruits, vegetables, and lean meats every day?

Yes

No

11. Do you regularly participate in any physical activity or exercise - for example, running, golf, calisthenics, gardening, etc.?

Yes

No

Women's Health

12a. Have you had a PAP test - to detect cervical cancer - within the last year?

Yes

No

12b. Have you had a mammogram - to detect breast cancer - within the last year?

Yes

No

12c. Are you currently pregnant?

Yes

No

13. Have you had a flu shot in the last 12 months?

Yes

No

14. Do you smoke pipes, cigars, cigarettes, vape or chew tobacco?

Yes

No

15. Do you exhibit behaviors that suggest that you have trouble with alcohol?

Yes

No

16. Have you ever had a blood stool test, colonoscopy, or sigmoidoscopy?

Yes

No

17. Have you suffered a personal loss or misfortune in the past 12 months, for example, job loss, divorce/separation, legal issues, disability, domestic violence, etc.?

Yes

No

18. In the past month have you been bothered by feeling down or hopeless?

Yes

No

19. During the past month, has stress had a major effect on your health?

Yes

No

20. Do you often miss work due to personal issues?

Yes

No

21. Have you been hospitalized in the last year?

Yes

No

21a. If you have been hospitalized in the last year, please explain:

22. Have you gone to the Emergency Room more than once in the last year?

Yes

No

22a. If you have gone to the Emergency Room more than once in the last year, please explain:

23. Do you wear your seatbelt?

Yes

No

24. Do you wear a helmet when biking?

Yes

No

25. Do you wear protective gear where recommended?

Not Applicable	Sometimes
Never	Always

Healthy Goals

26. Are you interested in setting health goals for activity, eating, weight loss, smoking, or other health goals?

Yes

No

27. Indicate your readiness for making changes or improvements in lifestyle behaviors:
(5 = Very ready to change... 1 = Not ready to change)

5

4

3

2

1

28. Lifestyle behavior that I want to change:

29. A customer service representative or a member of our medical management team is available to help with any questions or concerns regarding your coverage. If you would like us to contact you, please provide a phone number or email.

Todays Date

McLaren Health Plan encourages you to complete this health appraisal every year!

If have any questions regarding this survey or your health plan, please contact Customer Service at (888) 327-0671.

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Page Updated: 10/28/2023 11:56:25 AM

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