HMG Survey HMG Survey Name(Required) First Last Mobile Phone(Required)Email(Required) Have you been in the hospital or ER in the past 24 months?(Required) Yes No Do you take more than 3 medications daily?(Required) Yes No Do you have more than 1 specialist physician?(Required) Yes No Have you needed physical therapy in past 24 months?(Required) Yes No Do you sleep well and through the night?(Required) Yes No Are you eating well and have a good appetite?(Required) Yes No Are you walking well, with or without an assisted device?(Required) Yes No Do you have any bladder or bowl issues in the past year?(Required) Yes No Do you have any bladder or bowl issues in the past year?(Required) Yes No Have you fallen down in the past year?(Required) Yes No Do you live with any chronic pain?(Required) Yes No Is it hard to go visit your outside physicians ?(Required) Yes No Do you have any difficulty getting your medications?(Required) Yes No If you answered “Yes” to 3 or more questions, you qualify for our monthly evaluation program. It’s covered by most health insurances, and you may keep your current specialists and other doctors if you choose. By clicking submit, you agree to have a representative from Hansa Medical Groupe contact you regarding your inquiry and possibly schedule your evaluation.NameThis field is for validation purposes and should be left unchanged.
