SMM_Campaign Health Survey

Hidden

HouseholdID

Hello, my name is Agent calling from San Mateo Medical Center.

May I speak to First Name?

Hello, my name is Agent from San Mateo Medical Center.

May I speak to the parent or guardian of First Name?

Name

First Last

Date of Birth

Age

Gender

Male

Female

Patient Status

New Patient

Established Patient

Seeing Other Provider

Your medical home is Clinic Name,

located at: Address, Address2, City State, Zip Phone

You will be able to see a health care team who will give you the medical care you need for your health. This includes preventive and primary health care services and referrals to see specialists

We recommend that all new patients get an initial visit so that your provider will know if you are healthy or if you need anything to stay healthy.

In general, how would you rate your overall health?

How would you rate your overal health?

Have you been in to see your doctor within the past year?

Yes

Do you have a personal history of cancer? Did a parent or sibling have breast cancer?

Perfect!

We’re glad you’re one of our patients. If you need anything, please contact your clinic.

Do you have their phone number?

Clinic Name: Clinic Name

Clinic Number: Phone

We recommend that all adults see their provider at least once per year.

Please contact your clinic should you need anything. Do you have their phone number? Do you have their phone number?

Clinic Name: Clinic Name

Clinic Number: Phone

No problem!

Thank you for letting us know. If you ever decide you would like to see us, you can call the New Patient Connection Center at 650-372-3200.

Thank you so much for your time and have a great day!

No problem! Thank you for letting us know. If you ever decide you would like to see us, you can call Clinic Name at Phone. Thank you so much for your time and have a great day!

Do you have a personal history of cancer? Did a parent or sibling have breast cancer?

Yes

Would you like to make your first primary care appointment now? I am happy to transfer you to one of our staff who will help you find an appointment time that works for you. It won’t take long.

[If YES] – Warm handoff to New Patient Connection Center: 650-372-3200

[If NO] – No problem. Please contact the New Patient Connection Center at 650-372-3200 when you are ready to make your first appointment.

We recommend that all new patients get a checkup.

I am happy to transfer you to one of our staff who will help you find an appointment time that works for you. It won’t take long.

[If YES] – Warm handoff to appropriate clinic [Clinic_Phone_Number]

[If NO] – No problem. Please contact your clinic should you need anything

In the past year have you worried about running out of food or not being able to buy more?

Yes

If you need anything please call the New Patient Connection Center or your clinic. Thank you and have a good day.

Have you had a colonoscopy in the last 10 years?

Yes

That’s great!

Then you aren’t due for colon cancer testing.

You will receive the kit within 1 week and we ask you return the kit within 2 weeks of receiving it.

The kit will come with simple instructions and a prepaid envelope to mail back.

If you have any questions you can contact us at 650-372-3200.

Could you please confirm your mailing address?

Patient Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Have you had a cervical cancer screening, also called a pap-smear in the last 3 years?

Yes

Great.

It sounds like you do not need cervical cancer screening at this time, unless your previous test result was abnormal.

We are happy to schedule your pap smear appointment with our gynecology department located at the San Mateo Medical Center (on 39^th Ave in San Mateo).

IF AGREE – Transfer to OBGYN call center: 650-573-3702

Would you like to schedule a mammogram?

Yes

Clinic Name

Clinic Phone Number*

Clinic Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Hidden

Enroll Date

Hidden

Language

Hidden

HPSM Member Number

Hidden

Enroll Month Year

Hidden

New Enroll Flag

Comments

Disposition

Hidden

Health Suite Number

Hidden

Line of biz

Hidden

mcalaidcd

Hidden

Prior PCP

Hidden

SMMPCP

Hidden

IHA Done

Hidden

IHA Expire Date

Hidden

Campaign

Hidden

StartDate

Inbound Caller ID: Not Available

Campaign: Not Available

Client: Not Available

Agent: Not Available

External Links: Not Available

General Info: Not Available

Company: Not Available

Phone: Not Available

Contact: Not Available

Address: Not Available

Email: Not Available