Healthy Michigan Health Assessment

The Healthy Michigan Plan is very interested in helping you get healthy and stay healthy. We want to ask you a few questions about your current health. Your doctor and your health plan will use this information to better meet your health needs. The information you provide in this form is personal health information protected by federal and state law and will be kept confidential. It CANNOT be used to deny health care coverage.

We also encourage you to see your doctor for a check-up as soon as possible after you enroll with a health plan, and at least once a year after that. An annual check-up appointment is a covered benefit of the Healthy Michigan Plan. Contact your health plan if you need transportation assistance to get to and from this appointment.

If you need assistance with completing this form, contact your health plan. You can also call the Beneficiary Help Line at 1-800-642-3195 or TTY 1-866-501-5656 if you have questions.

You can also learn more at this website: www.healthymichiganplan.org.

Printable Healthy Michigan Assessment Form

Instructions for completing this Health Risk Assessment for Healthy Michigan Plan:

  • Answer the questions in sections 1-3 as best you can. You are not required to answer all of the questions.
  • Call your doctor’s office to schedule an annual check-up appointment. Take this form with you to your appointment.
  • Your doctor or other primary care provider will complete section 4. He or she will send your results to your health plan.
  • Don’t forget to complete a new health risk assessment each year.

After your appointment, keep a copy or printout of this form that has your doctor’s signature on it. This is your record that you completed your annual Health Risk Assessment.

* denotes required field

First Name, Middle Name, Last Name, and Suffix *

Date of Birth (mm/dd/yyyy) *

Mailing Address *

Apartment or Lot Number

mihealth Card Number *

City *

State *

Zip Code *

Phone Number *

Other Phone Number

SECTION 1 - Initial assessment questions (check one for each question)

Question 1

Question 2

Question 3

Question 4

Question 5

Question 6

Question 7

Question 7a

Question 8

Question 9

Question 10

Question 11

Question 12

Question 13

Question 14 A checkup is a visit to a doctor office that is NOT for a specific problem. How long has it been since your last checkup? *

SECTION 2 - Annual appointment

A routine checkup is an important part of taking car of your health. An annual check-up appointment is a covered benefit of the Healthy Michigan Plan and your health plan can help you with a ride to and from this appointment

Date of appointment (mm/dd/yyyy)*

At my appointment, I would most like to talk with my doctor about:

SECTION 3 - Readiness to change

Your Healthy Behavior

Small everyday changes can have a big impact on your health. Think about the changes you would be most interested in making over the next year. It is also important to get any health screenings recommended by your doctor.

Now that you have thought about your healthy behavior, answer questions 1 - 3. For each question, use the scale provided and pick a number from 0 - 5.

Question 1

Question 2

Question 3