| About You |
| 1. Name of person or child with CHIP, STAR Medicaid, STAR+PLUSor MAO DSNP: |
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| 2. What is the date of birth of the person in question #1? mm/dd/yyyy |
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| 3. Are you or your child male or female: |
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| 4. What is your relationship to this child? |
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| 5. What is your or your child's primary language? |
English
Spanish
Other
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| General Health |
| 6. In general, would you say that your or your child's health is: |
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| 7. How tall are you or your child? |
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| 8. How much do you or your child weigh? |
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| 9. What is your or your child's body mass index (BMI)? |
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| 10. What was your or your child's birth weight? |
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| 11. Were you or your child born prematurely, that is, more than 3 weeks before his or her due date? |
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| Special health care needs |
| 12. Do you or your child currently use any medicine prescribed by a doctor, other than vitamins? |
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| 13. Is your or your child's need for medicine because of ANY medical, behavioral, or other chronic illness (i.e., diabetes type 1 or 2, asthma, high blood pressure, etc)? |
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| 14. Is this a condition that has lasted or is expected to last 12 months or longer? |
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| 15. Has a doctor, health care provider, teacher, or school official ever told you that you or your child has a learning disability? |
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| 16. Would you describe the learning disability as: |
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| Type of Coverage/Access to Healthcare and Utilization |
| 17. Do you or your child have STAR, CHIP or MAO DSNP? |
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| 18. Is there a place that you USUALLY go to or take your child to when you or your child is sick or need advice about your's or your child's health? |
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| 19. What kind of place is it? |
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| 20. During the past 12 months or since birth,did you or your child see a doctor, nurse, or other health care professional for any kind of medical care, inlcuding sick-child care, well-child check ups, physical exams, and hospitalizations? |
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| 21. During the past 12 months have you or your child seen a dentist for dental check ups, cleanings, x-rays, or filling cavities? |
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| 22. Mental health professionals include psychiatrists, psychologists, psychiatric nurses, and clinical social workers. During the past 12 months have you or your child received any care from a mental health professional? |
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| Medical Home |
| 23. Do you or your child have a primary care doctor? |
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| 23a. Who is your or your child's primary care doctor? |
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| 24. During the past 12 months have you or your child needed a referral to see any specialists? |
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| 25. Was getting a referral a big problem, a small problem, or not a problem? |
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| 26. Overall are you satisfied with the communication among your child's doctors and yourself and/or other doctors or professionals? |
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| Smoking |
| 28. Does anyone living in your home smoke cigarettes, cigars, or pipe tobacco? |
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| 29. Do you or anyone smoke inside your or your child's home? |
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| 30. If you smoke, are you willing to quit? |
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| Socioeconomics |
| 31. Is it hard meeting basic needs for yourself or your family? For example: buying groceries, gas, clothes, school supplies, etc |
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| 32. Do you currently receive food stamps, TANF, housing, or another form of assisstance? |
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| 33. Do you or the parents or legal guardians of your child work full time jobs? (8 hours a day, 40 hours a week) |
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| 34. What is the main source of income? |
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| 35. What is your highest level of education or of that of the mother or legal guardian? |
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| 36. What is your highest level of education or of that of the father or legal guardian? |
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| Nutrition |
| 37. I or my child eats vegetables: |
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| 38. I or my child eats fruits: |
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| 39. I or my child eats out: |
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| 40. I or my child is active: |
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| 41. My child has sweet drinks (cola, sweet tea, juice, sports drinks, other juice drinks): |
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| 42. I or my child drinks water: |
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| 43. I or my child watches television or spends time on the computer or playing video games: |
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| 44. Have you thought about tyring a new healthy habit for yourself or your family or child? |
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| 45. If you could work on one healthy habit, which would it be? |
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