MassHealth Care Needs Screening

Please take a few minutes to complete this screening. Your Care Needs Screening will help Fallon Health provide better health services and coordinate the care you receive. We will keep the information you provide private. By submitting this form, you are giving us permission to share your information with the people involved in your care. Your answers will NOT affect your MassHealth/Medicaid benefits.

Answer all of the questions. Submit the form. Get a $10 gift card! (Limit: one card every 12 months.) 

Survey Instructions:

  1. Please fill out one screening form for each new member. If you are answering for your child and/or your family, please answer each question as it applies to your child and.or your family.
  2. You will need to have on hand:
    • The member's plan member ID number.
    • The name, phone number, and address of the member's doctor or nurse.
  3. Answer each of the questions by checking the appropriate box or filling in the space provided.
  4. You are sometimes told to skip over some questions in this survey. When this happens, you will see a note that tells you what question to answer next.
  5. This survey will take about 10 minutes to complete.
  6. You will receive a $10 CVS gift card upon completion (once per year).
  7. If you need help or have questions about completing this form, please call Customer Service at the number on the back of your member ID card, Monday through Friday from 8 a.m. to 6 p.m.
Information about the member's health needs
Q33a. If yes, please check all of the equipment the member uses.




Q36. Does the member have any of the following behavioral health conditions? (Question is for children/pediatric members ages 0-17 only.)








Q37. Does the member have any of the following medical diagnoses? (Question is for children/pediatric members ages 0-17 only.)




General member information
Q10. Member gender






If yes, please check as many as apply








Information about the member's health
Q19. Does the member have trouble doing any of the following things because of their health? Select all that may apply.







Q26. Does anyone in the member's family (mother, father, sister, brother, children) have any of the following health problems? Check all that apply.













Q27. Is the member being treated for any of the following health problems? Check all that apply.
















Q28. Has the member been told by a doctor that they have or have had any of the following conditions? Check all that apply.





Information about social well-being
Information about wellness and lifestyle
Q64. Who else lives in the home with the member? Please select as many as apply or select N/A.










Race and ethnicity
Q69. How would you describe the member's race? Please check as many as apply.







Q70. How would you describe the member's ethnic background? You may choose up to two options here. For example, 'American' or 'Mexican' or 'Cuban' and 'Puerto Rican.'