Health Risk Assessment

What is your gender? (so we can offer the right health care recommendations for you)

Male
Female

Are you currently pregnant?

Yes
No

What is your height? *

What is your weight *

What is your date of birth? *

What is your relationship status?

Married or in a committed relationship
Separated or divorced
Widowed
Single

What is the highest level of education you have received?

Do you ever need help filling out medical forms, reading prescription labels, or understanding doctors’ instructions?

On average, how many hours of sleep do you get at night?

How would you describe your outlook?

Pretty happy
Up and down
Often blue

How often do you wake up refreshed in the morning?

All or most of the time
Some of the time
Rarely or never

How often do you feel overwhelmed with stress?

Rarely
Sometimes
Often

Do you feel that stress is affecting your health?

Big time!
A little
No

Have you ever had depression?

Yes, currently
I used to
No

In the past 12 months, how many times have you missed work, school, or other obligations due to personal or family health issues?

Three or fewer
Four to six
Seven to nine
10 or more

Do you have supportive family and friends?

I have a great network
I have some friends
Limited
None

How often are you exposed to secondhand smoke?

Rarely
Sometimes
Often

How often do you worry about making ends meet?

Rarely or never
Sometimes
Often
All the time

In the past month, how many days of work did you miss because you were sick? *

What's your living situation?

Alone
With a spouse or partner
With roommates
Other

Do you have children?

Yes
No

Do you have a doctor or clinic for primary care?

Yes
No

Have you been treated by a Specialist within the last six months?

Yes
No

Have you had a Surgery within the last six months?

Yes
No

Have you visited the emergency room within the last six months?

Yes
No

Have you ever been diagnosed with sleep apnea?

Yes
No

How would you rate your diet on most days?

How many alcoholic drinks do you have in an average week?

I rarely or never drink
One or two
Three or four
Five or more

How often do you eat foods high in unhealthy trans or saturated fats? (Examples: red meat, butter, cheese, fried foods)

Under 4x a month
1 to 4x a week
5 to 6x a week
Once or more a day

In a typical month, do you ever have 5 or more drinks at a time (within about 2 hours)?

Yes
No

How many days a week do you exercise for at least 30 minutes?

None
One or two
Three or four
Five or more

How much activity do you do in a week?

None
Light (examples: standing, easy bicycling or walking)
Moderate (examples: fast walking, dancing)
Vigorous (examples: running, hiking, biking uphill)

How many days a week do you do weight- bearing exercise (weights, bodyweight)?

Never
Once
Two to three times
Four or more times

How confident are you that you're able to make healthy changes (like eat better, exercise more, or lose weight)?

I'm very confident
I think I can
Not sure I can
Not at all confident

What motivates you to try to be healthier?

How would you describe your cigarette smoking habits (traditional cigarettes, NOT e- cigarettes)?

I smoke every day
I smoke sometimes
I used to smoke
I've never smoked

How long have you smoked cigarettes?

On average, how many cigarettes do you smoke in a day?

How long ago did you stop smoking cigarettes?

Do you use other forms of tobacco or nicotine?

Have you been thinking about cutting down or quitting tobacco?

All the time
Sometimes
Not really

How many prescription medicines do you take daily or regularly?

How often do you take your prescription medicines as directed?

What keeps you from taking your prescription medicines as directed?

How many over-the-counter medicines and supplements do you take regularly?

Have you ever been diagnosed COPD?

Yes
No

Have you ever been diagnosed with Asthma?

Yes
No

How are you managing your asthma?

Quick-acting inhaler
Long-acting medicines
Both
None

Is your asthma under control?

Usually
Sometimes
Rarely

In the past three years, have you had a fasting blood sugar test?

Yes
No
I am not sure

What is your latest blood sugar reading?

What is your latest A1C reading?

Have you been diagnosed with diabetes or prediabetes?

Yes, diabetes
Yes, prediabetes
No

How are you managing your diabetes?

Have you had an eye exam and glaucoma test within the last year?

Yes
No
I don't know

Do you have heart disease, or have you had a stroke?

Yes
No

What kind of heart problems do you have?

Angina
Atrial fibrillation
Coronary heart disease
Other

Have you ever had a heart attack?

Yes
No

Have you ever had a stroke?

Yes
No

Are you under medical treatment or taking medication for your heart problems?

Medical Treatment
Taking Medication
Both
None

When was the last time you had your blood pressure checked?

What is your most recent blood pressure reading?

Has a doctor told you that you have high blood pressure?

Yes
No
I don't know

Are you taking any medicine for blood pressure?

Yes
No

When was the last time you had your cholesterol checked?

Has a doctor told you that you have high cholesterol?

Yes
No

Are you taking any medicines for cholesterol (statins)?

Yes
No

Do you have back problems?

Yes
No

Do your back problems affect your daily work, school, or recreational activities?

Rarely
Sometimes
Often

Are you under treatment by a physician for your back problems?

Yes
No

Do you have any arthritis or pain, aching, or stiffness in your joints?

No
Mild
Moderate
Severe

Does the pain or stiffness in your joints affect your daily work, school, or recreational activities?

Rarely
Sometimes
Often

When was your last screening for breast cancer (mammogram)?

Have you ever had breast or cervical cancer?

Breast
Cervical
Both
No

Do you have osteoporosis (brittle bones)?

Yes
No

When was the last time you had a screening for colorectal cancer?

What type of colorectal cancer screening did you have?

Do you have any vision problems or wear corrective lenses of any kind (eyeglasses, contact lenses)?

Yes
No

In general, would you say your health is:

Does your health limit you while doing moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf?

Yes, limited a lot
Yes, limited a little
No, not limited at all

In the past four weeks, has your physical health affected your work or other regular daily activities?

Yes, limited a lot
Yes, limited a little
No, not limited at all

Does your health limit you while climbing several flights of stairs?

Yes, limited a lot
Yes, limited a little
No, not limited at all

In the past four weeks, has your physical health affected your work or other regular daily activities? (Example: you accomplished less than you'd like)

Yes, all of the time
Yes, some of the time
None of the time

In the past four weeks, how often have your emotions interfered with getting things done? (Example: you accomplished less than you'd like)

In the past four weeks, how often have your emotions affected your work or other activities? (Example: you were not as attentive or careful as usual)

How much of the time during the past 4 weeks have you felt calm and peaceful?

In the past four weeks, how often have your emotions affected your work or other activities? (Example: you were not as attentive or careful as usual) (copy)

In the past four weeks, how often have you had a lot of energy?

How much of the time during the past 4 weeks have you felt downhearted or blue?

In the past four weeks, how often has your physical health or emotional problems interfered with your social activities? (like visiting with friends, relatives, etc.)

Compared to one year ago, how would you rate your physical health in general now?

Compared to one year ago, how would you rate your emotional health? (feeling anxious, depressed, or irritable)