Anthem Health Risk Assessment

Improve Your Anthem Plan for 2023

Below are questions Anthem created to identify key aspects of your health care needs so they can improve health care affordability and access for you on your Medicare plan next year. This questionnaire should take less than five minutes to complete.

Anthem Health Risk Assessment

First Name

Last Name

Date of Birth: Year

Date of Birth: Month

Date of Birth: Day

Address

City

State

ZIP Code

County

Phone

General Health

How would you rate your overall health?

Poor

Fair

Good

Very Good

Excellent

In the past three months, have you gone to an emergency room for care?

Yes

No

Were you admitted to the hospital anytime within the last 6 months?

Yes

No

Have you ever been diagnosed with Diabetes or blood sugar problems?

Yes

No

Have you ever been diagnosed with Coronary Artery Disease or other heart problems?

Yes

No

In the last 3 months, how many unplanned admissions to the hospital or Emergency Room for mental health or substance use issues have you had?

None

1 or 2

More than 2

Do you think you have a problem with alcohol or drugs?

Yes

No

Have you fallen two or more times in the last 3 months?

Yes

No

Do you require help with daily living skills?

Yes

No

Do you have the support that you need?

Yes

No

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