Health Questionnaire for HEDIS
In order to coordinate your care properly, it is important that you PLEASE provide the following information:

  1. Please provide the following contact information:

    Name
    Title
    Work Phone
    Home Phone
    E-mail

  2. Please identify and describe yourself:

    Date of Birth
    Sex Male Female
    Height
    Weight

  3. Please answer the following that apply:

    Do you have Rheumatoid Arthritis? Yes   No   
When was your last mammogram?   	                   
Do you have Diabetes? Yes   No
If Diabetes-When was your last Eye check? 
If Diabetes-When was our last urine test?  
When was your cholesterol last tested?	       
When was your last colonoscopy?
Author information goes here.
Copyright © 2003 [OrganizationName]. All rights reserved.
Revised: 12/06/11