Hello, HealthSCOPE Benefits is glad you are interested in our High Impact program! We have a lot of helpful information we can provide along with offering assistance with many of your health care needs when you are in our High Impact program.

This unique program will provide you with:

  • Free access to a 24 Hour CARE LINE, which includes an audio library covering many health related topics.
  • Information on diet, exercise and other topics that are important to your health.
  • Regularly scheduled contact with a Care Manager to discuss your medication and other health care needs, concerns or questions.

The first step to becoming a participant in the program is to complete the Patient Questionnaire. It should only take a few minutes and will help us determine the HIGH IMPACT program that will best fit you.

We look forward to working with you and hope to hear from you soon. Please feel free to give us a call at 1.800.972.3025 opt 5.

You may submit this information by mail. Our mailing address is:

HealthSCOPE Benefits
High Impact, Care Manager
27 Corporate Hill Drive
Little Rock, AR 72205

Patient Questionnaire

Thursday 7/2/2009 6:16 pm
Name: Member ID:
Age: Height: Weight:

  1. Do you take any of the following medications?

    Yes No Blood Pressure Medication
    Yes No Blood Thinners
    Yes No Diabetes Medications (High Sugar)
    Yes No Heart Medications
    Yes No Breathing Medications
    Yes No Pain Medications
    Yes No Depression or Anxiety Medications
    Yes No Other

  2. Do you have problems obtaining your medications?

    Yes No

  3. Has your Doctor ever told you that you have:

    Yes No Angina
    Yes No Chest Pain
    Yes No Diabetes
    Yes No Asthma
    Yes No Heart Disease
    Yes No High Blood Pressure
    Yes No Kidney Disease
    Yes No Stroke

  4. Do you ever feel "down in the dumps" or "blue"?

    YesNo

    If yes, how do you cope with it?

  5. How would you describe your Health?

    Excellent
    Good
    Fair
    Poor

  6. Are you on a special diet for:

    Heart Disease
    High Cholesterol
    Diabetes
    Weight Loss
    Stroke
    Kidney Disease
    Other

  7. Do you exercise regularly?

    Yes No

  8. Do you smoke?

    Yes No

    If yes, how much?

  9. Do you drink alcohol?

    Yes No

    If yes, how much?

  10. How do you feel you deal with stress?

    Good
    Fair
    Poor

  11. Would you change your lifestyle and behavior if it meant improving your health and life expectancy?

    Yes
    No
    No Comment

  12. In the past year, how many times have you seen a physician?

    12 or more times
    6-11 times
    4-5 times
    1-4 times

  13. In the past year, have you been hospitalized or received care in an emergency room?

    Yes No

    If yes, how many times?
    1-2 times
    3 or more times

    Why were you hospitalized?
    Accident
    Surgery
    Medical Condition

  14. Have you had any abnormal lab tests within the last year?

    Yes No

    If yes, what?

  15. Do you have a personal physician?

    Yes No

    Name of physician:

    Physician Phone #:   )   - 

  16. Do you feel you:

    Yes No Understand your healthcare benefits?

    Yes No Are able to talk with and understand your physician?

    Yes No Have a suppport system for illness or injury such as family and friends?

Phone number where we can contact you:   (    )   - 

 

Best time to call you: