MassHealth Managed Care Health Needs Questionnaire

Please take a few minutes to complete this survey. Your health needs questionnaire 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!

Survey Instructions:

  1. Please fill out one questionnaire for each new member annually (per year).
  2. You will need to have on hand:
    • Your Fallon Health member ID number.
    • The name, phone number, and address of your 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 Fallon Customer Service at 1-800-341-4848 (TRS 711), Monday through Friday from 8 a.m. to 6 p.m.
Member information
Q4. Gender

Information about you
Q20. If yes, please check as many as apply








Information about your health
Q23. If yes, please check as many as apply.







Q33. Does anyone in your family (mother, father, sister, brother, children) have any of the following health problems? Check all that apply.













Q34. Are you being treated for any of the following health problems? Check all that apply.
















Q35. Have you been told by a doctor that you have or have had any of the following conditions? Check all that apply.





Information about your health needs
Questions 38c and 38d are for women only.
Questions 38c and 38d are for women only.
Q40. If yes, please check all of the equipment you use.




Information about wellness and your lifestyle
Information about your race and ethnicity
Q59. How would you describe your race? Please check as many as apply.







Q60. How would you describe your ethnic background? You may choose up to two options here. For example, 'American' or 'Mexican' or 'Cuban' and 'Puerto Rican.'