Medicare Patient Health Risk Assessment (HRA) and History - sccipa 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information at the top of the form, including your name, date of birth, today's date, gender, age, and primary language.
3. In Section A, provide your medical history by checking the relevant conditions and indicating the approximate years you experienced them.
4. Move to Section B and answer questions about your social habits. Be sure to elaborate on any answers that require additional details.
5. For Section C, indicate any family history of medical issues by listing conditions and relationships.
6. In Section D, document any hospitalizations or surgeries you've had along with their dates.
7. List current medications and supplements in Section F, ensuring to include all relevant details for each entry.
8. Complete the functional ability screening in Section G by answering yes or no to each question regarding your daily activities.
9. Finally, fill out the depression screening questionnaire in Section H honestly. Your healthcare provider will review these responses.
10. Once completed, ensure you sign and date where indicated before submitting the form for review by your provider.

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