Medically Fragile Child Assessment

This short survey will only take a minute 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?*

Has your child been able to follow his/her treatment plan and visit the doctor as directed?*

Yes
Somewhat
No

Please let us know why your child hasn't been able follow his or her treatment plan.*

(Please check all that apply.)

I cannot afford it
Transportation issues
I have trouble making appointments with the doctor
My child's behavior makes it hard sometimes
Other

You selected "Other", why else has your child not been able to follow his or her treatment plan?*

Do you feel like you have the necessary support for managing your child’s condition?*

Yes
Somewhat
No

What type of support do you need?*

(Please select all that apply.)

Social
Medical
Financial
Spiritual
Caregiver

Are you flexible when unexpected things happen (Do you roll with the punches?)*

Yes
Somewhat
No

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

(Please select 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?*

Hidden

Health Rating Score

Hidden

Call CC

Hidden

Coping Strategies

Hidden

region

Hidden

county

Hidden

mobile

Hidden

status

Hidden

ChildName