Health Assessment Survey

We want to help you be as healthy as you can be with healthcare tailored to you. Fill out the form below to submit your request electronically. Print out
this form to submit by mail. ( Español )

If you would like help in submitting this information, please call member services at 1-888-778-1478 (TTY 711) 8 am–8 pm local time, 7 days a week.*

*Between April 1st and September 30th, alternate technologies (for example, voicemail) will be used on the weekends and holidays.




Date of Birth

By providing your email address and phone number(s), you consent to receiving information related to your membership with Clover Health (e.g., benefit information), programs and services offered (e.g., health education materials, reminders), marketing and other communications (e.g., newsletters, surveys) electronically. Communications related to your membership with Clover Health or healthcare may include auto-dialed calls, pre-recorded or electronic voice messages, or text messages. You may opt out of these means of communication at any time by clicking the "opt out" link within any email message, or contacting Clover Health, or responding STOP to a text message. You may also request a hard copy of any material that Clover Health delivers electronically.

What is the best method to reach you?

(Check all that apply)


What is the best time of day to reach you?

(Check all that apply)

Do you have an emergency contact—someone who helps with your medical care?


How are they related to you?

We will not talk with this person about your health unless you give us permission to do so. If you would like to give us permission to talk with this person, please complete the Voluntary Authorization for Disclosure of PHI form included in your Welcome Kit. You may also find the form online at


What problems, if any, do you have with staying healthy now?

(Check all that apply)


Where do you currently live?

Who do you live with?

(Check all that apply)

In general, how would you describe your health?
Do you currently smoke or have you smoked in the past?
Approximately how often do you exercise?
How often do you have a drink containing alcohol?
Are you unable to take part in activities such as moving a table, pushing a vacuum cleaner, bowling, or playing golf? If so, how much are you limited?
Do you use any of the following to help you walk or get around?

(Check all that apply)



Do you need help from another person to do any of the following activities?

(Check all that apply)

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

Little interest or pleasure in doing things in past 2 weeks?
Feeling down, depressed, or hopeless in past 2 weeks?
How often in the past 4 weeks have you had trouble thinking or remembering?
During the past 4 weeks, how often was someone available to help you if you needed help? For example, if you were sick and had to stay in bed, needed someone to talk to, and/or needed help with daily chores.
In the past year, have you been treated for any of the following conditions?

(Check all that apply)




How often are you able to take your medications as prescribed by your doctor?
How confident are you that you can control and manage most of your health problems?
Would you like help finding a primary care physician (a main doctor who coordinates your care)?
Did someone help you complete this form?

Thank you for completing this survey. Please send it back to us as soon as you can. If you have any questions, please call 1-888-778-1478 (TTY 711) 8 am–8 pm local time, 7 days a week.*

*Between April 1st and September 30th, alternate technologies (for example, voicemail) will be used on the weekends and holidays.


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