Health Risk Assessment Survey Form for Bupa Insurance Company

Health Risk Assessment Survey Form

Bupa Insurance Company

General Information:

Member Name: ….………………..Gender:  (  ) M (  ) F   Provider Name: ………………..

HIC*: ……………………………..DOB: …………          Date of service: ………………..  

IPA/MSO: ………………..                                                 Member ID: ……………………

NPI*: …………………….

Personal information:

Marital Status: ……………………………………

Smoking: (  ) Yes (  ) No   If yes kindly provide the rate of consumption

Alcohol:  (  ) Yes (  ) No   If yes kindly provide the rate of consumption   

Other drugs: (  ) Yes (  ) No If yes name the drug and the rate consumed

Family:

How many dependents do you have in your family?

1 (  )  2 (  ) 3 (  ) 4 (  ) More than 5 (  ) None (  ) 

  1. Pre –existing conditions

This is a health problem such as cancer, a person had prior before the date the new health coverage begins. The Company cannot refuse to cover treatment for a pre-existing conditions or in other case charge you more (Catov, Ness, & Olsen, 2007). Therefore, it is important for an individual to provide information on the previous health issues. Provide a clear history of your present illness:

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

How would you rate your overall health: (Please select one)

Poor (  )      Fair (  )     Good (  )    Excellent (  )   Note Sure (  )

What health conditions do you currently have? (Kindly mark each condition which applies to you)

  • Breathing problems caused by asthma or emphysema (  )
  • Diabetes or rather other sugar related problems           (  )
  • An enlarged heart or heart problem                              (  )
  • Kidney dialysis                                                             (  )
  • Depression                                                                    (  )
  • Heart related issues                                                       (  )
  • Other health conditions                                                (  )
  • NONE of the above conditions                                    (  )

In case you have one of the condition, please clarify whether you were fully treated and if not explain why………………………………………………………………..

  • History of physician Visitation

This involves visitation to a health care for medication or perhaps for a general consultation. The information is important for the Company in understanding a client’s rate of visitation to a health care. Moreover, it will allow the Company acquiring information for a future preparation while providing services to the client.

For the past three months, how many times have you visited a physician (Kindly indicate below)

 1 time (  ) 2-3 times (  ) 4 times (  ) 5 or more times (  ) none (  )

  • Lifestyle patterns that could lead to Illness

Lifestyle patterns involve the way an individual lives on a daily basis. It incapacitates what an individual eats, drinks and also does. It affects the general health of a person. For example, a person taking too much sugar is risking for diabetes and the same to one who consumers foods with high calorie content. The Company should have the information to effective evaluation of the client’s status (Currie, et al, 2009).

Dietary information

  • In the past one week, how frequent do you take high fiber or rather whole grains daily? It is imperative that every day we must be taking something for our survival. (One serving= one slice of 100% whole wheat bread, half cup of cooked cereals like oatmeal, one cup of high fiber ready to consume cereal or whole grain)
  • 0 (  )  B) 1-2 (  ) C) 3-5 (  )
  • For the past one week, how many sugar beverages and not diet did you consumer daily? (Kindly mark the number of times in the brackets below.)

None (  )  1 time (  ) 2 times (  ) 3-4 times (  ) 5 and above times (  )

  • How many fried or perhaps high fats foods did you eat daily for the past one month? (Kindly mark the number of times in the brackets below.)

I time (  )     2 times (  )    3 times (  )    4-5 times (  ) More than 5 times (  )   none (  )

  • Any other issues that would impact risk assessment and healthcare costs of individuals, and

The question of whether the client’s work place is safe is important to the Company. There are some clients’ who work in risky areas such as in factories which makes them prone to attacks. This information will be important for the Company in assisting the client have the right cover to suit the condition. It is imperative that an individual working in a bank will have less risk compared to the one working in a construction site (Turgiss, et al, 2011).

Physical evidence

  • Within the past one month, how much did pain intercept your normal operations such as walking, and other activities? (Select the appropriate answer form the list below)

Not at all (  ) a little bit (  ) moderately (  ) Quite a bit (  ) extremely (  )

  • In the past one month, has your health affected your ability to work or rather made you skip work? (Select the appropriate answer form the list below)

Not at all (  ) a little bit (  ) moderately (  ) Quite a bit (  ) extremely (  )

  • How often do you need to have someone else to assist you while reading any written materials?

Always (  )    Sometimes (  )    usually (  )    Never (  )

Safety measures

  • Are there safety measures at your work place such as proper precautions to shun or reduce workplace accidents?

Yea (  )  or No (  )    if yes, kindly provide a list of the safety equipment

Reasons

A health insurance firm is mandated to pay medical bills and other compensation to a client in case the client visits a healthcare. Therefore, to avoid much risk it is important for the insurer to balance the cost paid in terms of premiums and the risk. The questions on pre-existing condition will assist in the determination of premiums the clients should pay and also the possible risk. Moreover, the lifestyle patterns that could lead to health problems are important in the evaluation of the clients’ status. Most of the information that will be obtained through these questions will assist in allocating cost to be paid by the clients in terms of premiums (Alkhamis, 2013).

References

Alkhamis, A. (2013). A comparison of access to medical care for insured and uninsured expatriates in Saudi Arabia (Doctoral dissertation, University of Liverpool).

Catov, J. M., Ness, R. B., Kip, K. E., & Olsen, J. (2007). Risk of early or severe preeclampsia related to pre-existing conditions. International journal of epidemiology, 36(2), 412-419.

Currie, C., Zanotti, C., Morgan, A., Currie, D., De Looze, M., Roberts, C., … & Barnekow, V. (2009). Social determinants of health and well-being among young people. Health Behaviour in School-aged Children (HBSC) study: international report from the, 2010, 271.

Turgiss, J. L., Boylan, R. M., & Harrison, G. R. (2011). U.S. Patent No. 8,027,822. Washington, DC: U.S. Patent and Trademark Office.

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