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Health Risk Assessment

Birthdate

Gender

Male

Female

Non-binary

Ethnicity/Race

Do you have any special needs?

Check all that apply

Vision problems requiring large print or braille

Hearing problems requiring a TTY (text telephone)

What is your preferred language?

How were you able to access the Health Assessment?

Do you typically go to the Emergency Room more than 6 times a year?

Do you typically have to spend the night in the hospital more than 6 times a year?

Are you being evaluated for a transplant?

What is your height?

feet

inches

What is your weight? lbs.

What is your waist size? Inches

What are your plans for losing weight?

No change is needed

Maintained changes for 6+ months

Started making changes already

Plan to change within the month

Plan to change in the next 6 months

No plans to change

What is your resting heart rate?

BPM

Not Sure

Since you're not sure, can you give us a range?

Low (≤100 bpm)

High (>100 bpm)

I still am not sure

What is your blood pressure?

mm Hg

Not Sure

Since you're not sure, can you give us a range?

Normal (<120/80 mm/Hg)

Prehypertensive (120/80 – 139/89 mm/Hg)

High (140/90 – 159/99 mm/Hg)

Very High (≥160/≥100 mm/Hg)

Elevated (120/<80 - 129/<80 mm/Hg)

Stage 1 (130/80 - 139/89 mm/Hg)

Stage 2 (≥140/≥90 mm/Hg)

I still am not sure

What is your total cholesterol?

mg/dL

Not Sure

Since you're not sure, can you give us a range?

Normal (<200 mg/dL)

Borderline high (200 – 239 mg/dL)

High (≥240 mg/dL)

I still am not sure

What is your HDL (good) cholesterol?

mg/dL

Not Sure

Since you're not sure, can you give us a range?

Low (<50 mg/dL)

Moderate (50 – 59 mg/dL)

High (≥60 mg/dL)

I still am not sure

Did you fast for your triglycerides test?

Yes

What are your triglycerides?

mg/dL

Not Sure

Since you're not sure, can you give us a range?

Normal (<150 mg/dL)

Borderline high (150 – 199 mg/dL)

High (200 – 499 mg/dL)

Very high (≥500 mg/dL)

Normal (<200 mg/dL)

High (≥200 mg/dL)

I still am not sure

Did you fast for your glucose test?

Yes

What is your glucose?

mg/dL

Not Sure

Since you're not sure, can you give us a range?

Normal (<100 mg/dL )

Pre-diabetic (100 – 125 mg/dL)

Diabetic (≥126 mg/dL)

Normal (<140 mg/dL)

Pre-diabetic (140 – 199 mg/dL)

Diabetic (≥200 mg/dL)

I still am not sure

On average, how many servings of fruit do you eat per day?

0-1 serving

2 servings

3 servings

4+ servings

On average, how many servings of vegetables do you eat per day?

0-1 serving

2 servings

3 servings

4+ servings

On average, how many servings of whole grains do you eat per day?

0-1 serving

2 servings

3 servings

4+ servings

How often do you eat foods high in saturated fat?

Less than once a week

Once a week

Several times a week

Once a day

Several times a day

What are your plans for eating healthier?

No change is needed

Maintained changes for 6+ months

Started making changes already

Plan to change within the month

Plan to change in the next 6 months

No plans to change

How many total minutes do you exercise per week?

0 minutes

30 minutes

60 minutes

90 minutes

120 minutes

150+ minutes

During exercise, how hard do you work?

Normal

Moderate

Hard

What are your plans for getting more exercise?

No change is needed

Maintained changes for 6+ months

Started making changes already

Plan to change within the month

Plan to change in the next 6 months

No plans to change

What is your smoking status?

Current smoker

Quit smoking

Never smoked

What is the total number of years you have smoked?

How long have you been tobacco free?

Less than 6 months

Greater than 6 months

6 months or longer

How many cigarettes do you smoke in one day?

Less than 1/2 pack

1/2 - 1 pack

1 - 2 packs

2+ packs

Do you use other tobacco products?

Yes

Which of the following tobacco products do you use?

Chewing tobacco

Cigars

Pipe

Snuff/dip

E-Cigarettes

Hookah

(check all that apply)

What are your plans for quitting tobacco use?

Started making changes already

Plan to change within the month

Plan to change in next 6 months

No plans to change

How many alcoholic drinks do you have in a typical week?

What are your plans for modifying alcohol use?

No change is needed

Maintained changes for 6+ months

Started making changes already

Plan to change in next month

Plan to change in the next 6 months

No plans to change

How many hours of sleep do you usually get a night?

How often do you read or send text messages or e-mails while driving?

I never do this

I sometimes do this

I do this all the time

In the last month, how often have you felt that you were unable to control the important things in your life?

Never

Almost never

Sometimes

Fairly often

Very often

In the last month, how often have you felt confident about your ability to handle your personal problems?

Never

Almost never

Sometimes

Fairly often

Very often

In the last month, how often have you felt that things were going your way?

Never

Almost never

Sometimes

Fairly often

Very often

In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?

Never

Almost never

Sometimes

Fairly often

Very often

What are your plans for managing stress?

No change is needed

Maintained changes for 6+ months

Started making changes already

Plan to change in next month

Plan to change in the next 6 months

No plans to change

Little interest or pleasure in doing things?

Yes

How often have you been bothered by this?

Not at all

Several days

More than half the days

Nearly every day

Feeling down, depressed or hopeless?

Yes

How often have you been bothered by this?

Not at all

Several days

More than half the days

Nearly every day

Trouble falling or staying asleep, or sleeping too much?

Not at all

Several days

More than half the days

Nearly every day

Feeling tired or having little energy?

Not at all

Several days

More than half the days

Nearly every day

Poor appetite or overeating?

Not at all

Several days

More than half the days

Nearly every day

Feeling bad about yourself—or that you are a failure or have let yourself or your family down

Not at all

Several days

More than half the days

Nearly every day

Trouble concentrating on things, such as reading the newspaper or watching television

Not at all

Several days

More than half the days

Nearly every day

Moving or speaking so slowly that other people could have noticed. Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual

Not at all

Several days

More than half the days

Nearly every day

Do you have a doctor or health care provider?

Yes

Have you seen your doctor or health care provider within the last 12 months?

Yes

In general, how would you rate your health?

Excellent

Very good

Good

Fair

Poor

Please check which type of cancer?

Blood Cancer

Breast Cancer

Cervical Cancer

Colon Cancer

Lung Cancer

Prostate Cancer

Skin Cancer

Uterine Cancer

Aspirin

Yes

Blood pressure medication

Yes

Cholesterol medication

Yes

Do you get a mammogram to check for breast cancer at least every 2 years?

Yes

Do you get a mammogram to check for breast cancer every year?

Yes

Have you had a double mastectomy?

Yes

Have you had a pap smear in the last 3 years?

Yes

Have you had a hysterectomy?

Yes

Have you been screened for colon cancer?

Yes

Have you gotten a flu shot in the last 12 months?

Yes

Have you and your healthcare provider discussed surgery as an option for any current condition(s)?

Yes

Which type of surgery?

Cardiothoracic (heart or lung)

Ears, Nose and Throat

General Surgery (gallbladder, hernia, digestive tract)

Ophthalmology (Eye)

Neurosurgery (neck, brain, spinal cord)

Orthopedic (back, bone, muscle, joint)

Veins and arteries

Woman’s Health (uterus or cervix)

(check all that apply)

Are you pregnant?

Yes

Have you given birth within the last 12 months?

Yes

Have you ever had gestational diabetes?

Yes

How many years has it been since you last had it?

Have you gone through menopause?

Yes

Experiencing Now

Do you take hormone replacement therapy?

Yes

Are you currently employed?

Yes

During the past seven days, how many hours did you miss from work because of your health problems?

During the past seven days, how many hours did you miss from work because of any other reason, such as vacation, holidays, time off to participate in this study?

During the past seven days, how many hours did you actually work?

During the past seven days, how much did your health problems affect your productivity while you were working?

Enter 0 if your health problems had no effect on my work. Enter 10 if your health problems completely prevented me from working

During the past seven days, how much did your health problems affect your ability to do your regular daily activities, (other than work at a job)?

Enter 0 if your health problems had no effect on my work. Enter 10 if your health problems completely prevented me from working