McLaren Health Plan
Medicaid and Healthy Michigan Plan Member Survey

At McLaren Health Plan, we care about your privacy. The Protected Health Information (PHI) we use or disclose is private. Only people who have both the need and the legal right may see your PHI.

This survey should be completed and returned to McLaren Health Plan via mail, online by using the QR Code or visiting McLarenHealthPlan.org.

References:

The questions in this survey are adapted from various validated sources to ensure comprehensive and accurate assessment. For a detailed list of references and permissions, please visit our MHP Member Survey References Page.

Additionally, many of these questions are derived from The AHC Health-Related Social Needs Screening Tool developed by the Centers for Medicare & Medicaid Services (CMS). For more information, you can access the full screening tool document here.

Who is completing the survey? *

Personal Information

Member Name *

Address: *

Preferred Language: *

Health care support

Current Primary Care Physician: *

Emergency room visits:

Have you been a patient in the emergency room two or more times in the past six months? *

Yes

No

Additional Support:

Do you need help finding a doctor? *

Yes

No

If you have needs that make being healthy difficult, would you like someone from our team to help you with those needs? *

Yes

No

Living Situation

What is your living situation today? *

I have a steady place to live

I have a place to live today, but I am worried about losing it in the future

I do not have a steady place to live (I am temporarily staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, abandoned building, bus or train station, or in a park)

Think about the place you live. Do you have problems with any of the following? *

CHOOSE ALL THAT APPLY

Pests such as bugs, ants, or mice

Mold

Lead paint or pipes

Lack of heat

Oven or stove not working

Smoke detectors missing or not working

Water leaks

None of the above

Food

Some people have made the following statements about their food situation. Please answer whether the statements were OFTEN, SOMETIMES, or NEVER true for you and your household in the last 12 months.

Within the past 12 months, you worried that your food would run out before you got money to buy more. *

Often true

Sometimes true

Never true

Within the past 12 months, the food you bought just did not last and you did not have money to get more. *

Often true

Sometimes true

Never true

Transportation

In the past 12 months, has lack of reliable transportation kept you from medical appointments, meetings, work or from getting things needed for daily living? *

Yes

No

Utilities

In the past 12 months, has the electric, gas, oil, or water company threatened to shut off services in your home? *

Yes

No

Already shut off

Safety

Because violence and abuse happens to a lot of people and affects their health we are asking the following questions.

How often does anyone, including family and friends, physically hurt you? *

Never

Rarely

Sometimes

Fairly often

Frequently

How often does anyone, including family and friends, insult or talk down to you? *

Never

Rarely

Sometimes

Fairly often

Frequently

How often does anyone, including family and friends, threaten you with harm? *

Never

Rarely

Sometimes

Fairly often

Frequently

How often does anyone, including family and friends, scream or curse at you? *

Never

Rarely

Sometimes

Fairly often

Frequently

Financial Strain

How hard is it for you to pay for the very basics like food, housing, medical care, and heating? Would you say it is: *

Very hard

Somewhat hard

Not hard at all

Employment

Do you want help finding or keeping work or a job? *

Yes, help finding work

Yes, help keeping work

I do not need or want help

Family and Community Support

If for any reason you need help with day-to-day activities such as bathing, preparing meals, shopping, managing finances, etc., do you get the help you need? *

I do not need any help

I get all the help I need

I could use a little more help

I need a lot more help

How often do you feel lonely or isolated from those around you? *

Never

Rarely

Sometimes

Often

Always

Education

Do you speak a language other than English at home? *

Yes

No

Do you want help with school or training? For example, starting or completing job training or getting a high school diploma, GED or equivalent. *

Yes

No

Physical Activity

In the last 30 days, other than the activities you did for work, on average, how many days per week did you engage in moderate exercise (like walking fast, running, jogging, dancing, swimming, biking, or other similar activities)? *

0
1
2
3
4
5
6
7

On average, how many minutes did you usually spend exercising at this level on one of those days? *

0
10
20
30
40
50
60
90
120
150 or greater

Substance Use

The next questions relate to your experience with alcohol, cigarettes, and other drugs. Some of the substances are prescribed by a doctor (like pain medications), but only count those if you have taken them for reasons or in doses other than prescribed. One question is about illicit or illegal drug use, but we only ask in order to identify community services that may be available to help you.

How many times in the past 12 months have you had 5 or more drinks in a day (males) or 4 or more drinks in a day (females)? One drink is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits. *

Never

Once or Twice

Monthly

Weekly

Daily or Almost Daily

How many times in the past 12 months have you used tobacco products (like cigarettes, cigars, snuff, chew, electronic cigarettes)? *

Never

Once or Twice

Monthly

Weekly

Daily or Almost Daily

How many times in the past year have you used prescription drugs for non-medical reasons? *

Never

Once or Twice

Monthly

Weekly

Daily or Almost Daily

How often in the past year did you use marijuana? *

Never

less than monthly

monthly

weekly

daily

How many times in the past year have you used illegal drugs? *

Never

Once or Twice

Monthly

Weekly

Daily or Almost Daily

Mental Health

Over the past 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things? *

Not at all

Several days

More than half the days

Nearly every day

Feeling down, depressed, or hopeless? *

Not at all

Several days

More than half the days

Nearly every day

Stress means a situation in which a person feels tense, restless, nervous, or anxious, or is unable to sleep at night because his or her mind is troubled all the time. Do you feel this kind of stress these days? *

Not at all

A little bit

Somewhat

Quite a bit

Very much

Conditions

Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? *

Yes

No

Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor

Yes

No

Oral Health

Do you have a regular dentist you see for checkups? *

Yes

No

Are you currently experiencing issues with your teeth or mouth? *

Pain or Discomfort

Gum Disease

Tooth Decay or Cavities

Missing Teeth

Other

None

Captcha*