Health Risk Assessment Page 4
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5First Name, Middle Name, Last Name, and Suffix
mihealth Card Number
Section 4 – To be completed by your primary care provider
Primary care providers should fill out this form for Healthy Michigan Plan beneficiaries enrolled in Managed Care Plans
only. Fill in the Member Results, select a Healthy Behavior statement in discussion with the member, and sign the
Primary Care Provider Attestation. Blood pressure, BMI and tobacco use status will be known from the appointment. For
all other Member Results, marking the result as unknown and indicating whether the screening or immunization is
recommended satisfies the requirements for a complete Health Risk Assessment. All three parts of Section 4 must be
filled in for the attestation to be considered complete.
Member Results
Blood Pressure
(xxx/xxx mmHg)
Yes
No
Patient diagnosed with hypertension?
BMI
In the context of all relevant clinical factors, does this BMI indicate
Ht
Wt.
Yes
No
need for weight management?
BMI
(xx.x)
Tobacco Use Status
Never used tobacco
Previous tobacco user
Current tobacco cessation
Starting tobacco cessation
Tobacco user
Cholesterol
Yes
No
Yes
No
Cholesterol known?
Patient diagnosed with high cholesterol?
If cholesterol known is Yes:
Total cholesterol:
LDL:
Date of most recent test results:
HDL:
Triglycerides:
If cholesterol known is No:
Screening not recommended
Screening Ordered
Blood Sugar
Yes
No
Yes
No
Blood sugar known?
Patient diagnosed with diabetes?
If blood sugar known is Yes:
FBS (xxx mg/dl):
Date of most recent test results:
A1C (xx.x%):
If blood sugar known is No:
Screening not recommended
Screening Ordered
Influenza Vaccine
Yes
No
Annual Influenza Vaccination?
If Influenza vaccination is Yes:
Date of most recent vaccination:
If Influenza vaccination is No:
Vaccination not recommended
Vaccination recommended
DCH-1315 (03/14)
Page 4 of 5
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