Magellan Complete Care of Florida (MCC of FL)

Adult health assessment

Magellan Complete Care, your health plan, wants to help you feel better and enjoy a healthy life.

These health questions will help us to better understand how you are feeling. It will help us know what services and resources you will need to stay healthy and feel well. The questions will take you about 15 minutes to complete. If you need help filling out this form, please call us at 800-327-8613 (TTY 711).

As your health plan it is key that we work very closely with your doctors. We make sure you get the care you need. If you give us the OK, we can share this information with your doctors. This will make sure you get good care and help your doctors talk to each other. Without your OK, we will not share any information with anyone.”

Fields marked with an * are required. 

Please fill out the following form.
Do you agree for us to share your answers with your doctors?
About You
Sex *
Other Insurance
Do you have reliable transportation to appointments? *
Where do you currently live? *
Who do you live with? *
Are you worried you may not have stable housing in the next two months? This could be housing that you own, rent or where you stay with family or friends.
Do you have a caregiver or someone we can contact if we can't reach you?
If yes, do you give Magellan Complete Care permission to give information to this person?
About Your Physical Health
Compared to others your age, how would you rate your overall health? *
Do you have any concerns about your health or physical well-being? *
Do you have any of the following?
Are you currently pregnant? *
About Care You Receive
How many times have you been seen in the Emergency Room in the last 3 months? *
How many times have you been admitted to the hospital in the last 3 months? *
How many prescriptions/medications (other than vitamins) do you take? *
Do you use any medical equipment or other assistive devices? *
Do you get assistance with Activities of Daily Living such as dressing, feeding, bathing?
Write "N/A" if you do not currently have a primary care provider
Write "N/A"if you do not currently have a behavioral health provider
Write "N/A" if you do not currently have a dentist
Have you had any of the following done in the last 12 months?
What number best describes how much, during the past week, pain has affected with your general activity?
About Your Lifestyle
How many meals do you eat on a regular day? *
How often do you eat fast food, processed foods (such as chicken nuggets, hot dogs, bologna) or fried foods? *
Which best describes your use of tobacco products? *
How many drinks of alcohol do you have in a typical week? (A drink=12 oz. of beer, a 5 oz. glass of wine, a 12 oz. wine cooler, or a shot of whisky) *
Do you have any substance use concerns? *
How would you describe your physical activity/exercise level? *
In the past 4 weeks, how many days did you miss from work or school because of problems with your physical or mental health? (Please include only days missed for your own health, not someone else's health.) *
During the past 7 days, how much did your physical or mental health affect you being able to do things at work or at school?
About Your Emotional Health
How often do you feel stressed? *

Over the past 2 weeks, how often have you (has your child) been bothered by any of the following problems?

Little interest or pleasure in doing things? *
Feeling down, depressed or hopeless? *
About Your Future Health
How important is it to you to make a change to your health right now? *
How confident are you about making a change to your health right now? *
How ready are you to make a change to your health right now? *