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Adult - Health Risk Assessment

Please Complete one form for each person in your family who is enrolled in LIBERTY.  If you have questions, please call LIBERTY, toll free at 1.833.276.0850.  A representative is available to speak with you Monday through Friday, between 8:00 am and 7:00 pm.  TDD/TTY users should dial 1.877.855-8039.

 

Filling out this form is voluntary. You will not be denied care based on your confidential answers.

Member's First Name:
Member's Last Name:
Date of Birth:
Medicaid ID Number:
1. Has it been more than 12 months since your last dental visit?

2. Do you have pain when eating cold, hot, or sugary foods?

3. Do you have painful tooth eruption?

4. Do you have an infected tooth or teeth?

5. Do you have a broken tooth or teeth?

6. Is your mouth dry?

7. Do your gums bleed when you brush or floss?

8. Have you had any gum (periodontal) treatments?

Date of last treatment:
9. Do you wear dentures or partials?

10. Are you currently receiving radiation or chemotherapy?

11. Are you pregnant?

12. Do you see a doctor regularly for a chronic medical condition?

Check all that apply:


13. Do you have or associate yourself with a mental or physical disability?

I understand that this information will be disclosed to my new dental plan.
If you think you need to see a dentist before LIBERTY contacts you, please contact your dental office or seek care from a hospital.

Please only click Submit once