Home > Minnesota Child Care Association Health Benefit Program > MCCA Personal Health Questionnaire Do you plan on enrolling in the Association Affinity Health Plans?(Required) I plan on enrolling in the Health Plan I plan on waiving coverage from the Health Plan Member Name(Required) First Last Phone(Required)Email(Required) Address(Required) Street Address Address Line 2 City State Zip Company Name(Required)Hire Date(Required) MM slash DD slash YYYY Pharmacy Assistance Program Income QualificationPlease input the range of your pre-tax household yearly income. This information is used solely to verify Federal Poverty Level (FPL) and apply potential pharmaceutical savings and will not be shared with any third-party.Yearly Income(Required)1. Demographic Build & Tobacco UseAnswer all of the following questions for yourself and enrolling family members. All questions must be answered, or the form may not be accepted. Name First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemaleHeight (ft)Height (in)Weight (lb)Tobacco Use in the Last Year?(Required) Yes No Are you adding a Spouse/Domestic Partner?(Required) Yes No Spouse/Domestic Partner Name First Last Are you adding a Child/Children?(Required) Yes No Please list Child/Children(s) First and Last Name2. Medical Conditions & TreatmentsHas any person listed above seen a medical provider, had treatment recommended, received care (including prescriptions) or been hospitalized for any of the following with in the last 5 years? Check 'Yes' or 'No' for each question. Please complete Additional Detail Section for all 'YES' answers.1. Cancer(Required) Yes No 2. Cardiac or Heart Disease/Disorder(Required) Yes No 3. Diabetes(Required) Yes No 4. High Cholesterol(Required) Yes No List the three most recent Cholesterol Readings:5. High Blood Pressure(Required) Yes No 6. Arthritis (i.e. rheumatoid, osteo, psoriatic, grout)(Required) Yes No 7. Autoimmune Disease (i.e. Iupus, MS, anemia)(Required) Yes No 8. Back Disorder (i.e. degenerative disk disease, herniated disk, spinal fusion, spondylitis, strain)(Required) Yes No 9. Benign Growth (i.e. tumor, cyst)(Required) Yes No 10. Bowel (i.e. irritable bowel IBS, Crohn's ileitis)(Required) Yes No 11. Circulatory System Disease (i.e. stroke, arterial/vascular disease)(Required) Yes No 12. Immunodeficiency (i.e. AIDS, HIV+, hemophilia)(Required) Yes No 13. Kidney Disorder (i.e. nephritis, renal failure)(Required) Yes No 14. Liver Disease (i.e. cirrhosis, hepatitis A, B, C, E)(Required) Yes No 15. Mental Illness (i.e. mild or major depression, anxiety, bipolar disorder, or schizophrenia)(Required) Yes No 16. Counseling (current or prior counseling?)(Required) Yes No 17. Muscular Disorder(Required) Yes No 18. Respiratory (i.e. asthma, allergies, pneumonia, COPD, emphysema, bronchitis)(Required) Yes No 19. Stomach (i.e. ulcer, acid reflux, GERD)(Required) Yes No 20. Substance dependency (i.e. alcohol, drug)(Required) Yes No 21. Transplants(Required) Yes No List or Organ(s)22. Is anyone currently taking prescription medication(s)?(Required) Yes No 23) Is anyone had any of the following for a serious illness in the past 5 years?(Required) a) Treatment b) Hospitalization c) Surgery d) No 24a) Is anyone currently, hospitalized or confined in a treatment facility?(Required) Yes No 24b) Is anyone currently, hospitalized or confined in a treatment facility?(Required) Yes No 25a) Is any of the following pending, treatment (medical treatment or diagnostic testing)?(Required) Yes No 25b) Is any of the following pending, hospitalization?(Required) Yes No 25c) Is any of the following pending, surgery?(Required) Yes No 26. In the past 5 years, has anyone enrolling had symptoms of any serious medical condition not yet indicated on this form?(Required) Yes No 27. Is anyone pregnant?(Required) Yes No Additional Details SectionPlease provide further detail on all 'Yes' answers selected aboveDigital Signature(Required)Signature Date(Required) MM slash DD slash YYYY Please verify you are not a bot MCCA Personal Health Questionnaire – English Do you plan on enrolling in the Association Affinity Health Plans?(Required) I plan on enrolling in the Health Plan I plan on waiving coverage from the Health Plan Member Name(Required) First Last Phone(Required)Email(Required) Address(Required) Street Address Address Line 2 City State Zip Company Name(Required)Hire Date(Required) MM slash DD slash YYYY Pharmacy Assistance Program Income QualificationPlease input the range of your pre-tax household yearly income. This information is used solely to verify Federal Poverty Level (FPL) and apply potential pharmaceutical savings and will not be shared with any third-party.Yearly Income(Required)1. Demographic Build & Tobacco UseAnswer all of the following questions for yourself and enrolling family members. All questions must be answered, or the form may not be accepted. Name First Last Date of Birth(Required) MM slash DD slash YYYY Gender(Required)MaleFemaleHeight (ft)Height (in)Weight (lb)Tobacco Use in the Last Year?(Required) Yes No Are you adding a Spouse/Domestic Partner?(Required) Yes No Spouse/Domestic Partner Name First Last Are you adding a Child/Children?(Required) Yes No Please list Child/Children(s) First and Last Name2. Medical Conditions & TreatmentsHas any person listed above seen a medical provider, had treatment recommended, received care (including prescriptions) or been hospitalized for any of the following with in the last 5 years? Check ‘Yes’ or ‘No’ for each question. Please complete Additional Detail Section for all ‘YES’ answers.1. Cancer(Required) Yes No 2. Cardiac or Heart Disease/Disorder(Required) Yes No 3. Diabetes(Required) Yes No 4. High Cholesterol(Required) Yes No List the three most recent Cholesterol Readings:5. High Blood Pressure(Required) Yes No 6. Arthritis (i.e. rheumatoid, osteo, psoriatic, grout)(Required) Yes No 7. Autoimmune Disease (i.e. Iupus, MS, anemia)(Required) Yes No 8. Back Disorder (i.e. degenerative disk disease, herniated disk, spinal fusion, spondylitis, strain)(Required) Yes No 9. Benign Growth (i.e. tumor, cyst)(Required) Yes No 10. Bowel (i.e. irritable bowel IBS, Crohn's ileitis)(Required) Yes No 11. Circulatory System Disease (i.e. stroke, arterial/vascular disease)(Required) Yes No 12. Immunodeficiency (i.e. AIDS, HIV+, hemophilia)(Required) Yes No 13. Kidney Disorder (i.e. nephritis, renal failure)(Required) Yes No 14. Liver Disease (i.e. cirrhosis, hepatitis A, B, C, E)(Required) Yes No 15. Mental Illness (i.e. mild or major depression, anxiety, bipolar disorder, or schizophrenia)(Required) Yes No 16. Counseling (current or prior counseling?)(Required) Yes No 17. Muscular Disorder(Required) Yes No 18. Respiratory (i.e. asthma, allergies, pneumonia, COPD, emphysema, bronchitis)(Required) Yes No 19. Stomach (i.e. ulcer, acid reflux, GERD)(Required) Yes No 20. Substance dependency (i.e. alcohol, drug)(Required) Yes No 21. Transplants(Required) Yes No List or Organ(s)22. Is anyone currently taking prescription medication(s)?(Required) Yes No 23) Is anyone had any of the following for a serious illness in the past 5 years?(Required) a) Treatment b) Hospitalization c) Surgery d) No 24a) Is anyone currently, hospitalized or confined in a treatment facility?(Required) Yes No 24b) Is anyone currently, hospitalized or confined in a treatment facility?(Required) Yes No 25a) Is any of the following pending, treatment (medical treatment or diagnostic testing)?(Required) Yes No 25b) Is any of the following pending, hospitalization?(Required) Yes No 25c) Is any of the following pending, surgery?(Required) Yes No 26. In the past 5 years, has anyone enrolling had symptoms of any serious medical condition not yet indicated on this form?(Required) Yes No 27. Is anyone pregnant?(Required) Yes No Additional Details SectionPlease provide further detail on all ‘Yes’ answers selected aboveDigital Signature(Required)Signature Date(Required) MM slash DD slash YYYY Please verify you are not a bot