Brief Survey | Fidelis Care

This short survey will only take a few minutes to complete and will help us monitor how you are doing. If you are a caregiver, please answer the questions as they relate to the Fidelis Care member identified below.

Name

First Last

How would you rate your level of overall health and well-being?*

How often have they been bothered by the following over the past 2 weeks?

Feeling nervous, anxious, or on edge*

Not at all
Several days
More than half of the days
Nearly every day

Not being able to stop or control worrying*

Not at all
Several days
More than half of the days
Nearly every day

What coping skills do you use when you are stressed, sad, anxious or angry?*

(Please check all that apply.)

Breath focus
Body scan
Guided imagery
Mindfulness meditation
Rhythmic movement and mindful exercise
I don’t know what some, most or all of these skills are
I use a different coping skill

What other coping skill do you use?*

Would you like more information on different resources and support groups that are available to support you in managing your condition?*

Yes
No

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Health Rating Score

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GAD-2 Score

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GAD-7 Confirmation

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CALL CC

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COPING CONFIRMATION

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region

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county

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mobile

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status

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