Health Assessment

Health Assessment
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Your plan for better health begins with completing this health assessment. The answers to this
assessment will help us to identify programs and resources that are available at no cost to you.
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After your health assessment is received by our wellness team, they will generate a
personalized report and mail it to you within 30 days. Your health report will include a wellness
score as well as valuable tips and recommendations on how to maintain or enhance your
health.
Instructions
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Use a pen or pencil
Make sure all bubbles are filled in completely
Please answer all applicable questions
Return your completed health assessment and survey in the enclosed postage-paid
envelope
Consent
The information below describes how your personal information will be safeguarded and used
to develop your Health Assessment Report. Please read and sign to agree to the terms.
Health Assessment Notice to End Users
Use of Personal Information
The information you submit in the course of taking the attached health assessment will be
retained and used to create your Health Assessment Report. Your answers will be combined
with other participants’ data for reporting purposes. You will not be personally identified.
Terms of Use
By participating in the health assessment you agree that the results of the assessment will be
used for instructive purposes only. The health assessment is not intended to and cannot replace
the advice of a medical professional. You should not rely on the health assessment or Health
Assessment Report for diagnosis or treatment. All people who display disease symptoms, fall
into certain high risk categories, and/or who receive abnormal laboratory test results should
consult a physician before starting any course of action or lifestyle change.
Consent
By signing below you acknowledge that you have read, understood, and agree to the above and
assert that you are at least 18 years of age.
Signature: _________________________________________ Date: ___________________
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My Profile
Date:
(mm/dd/yyyy)
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Number & Street Address
City
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I. Last Name
First Name
State
Zip Code
Date of Birth:
Email address:
Gender:
Female
Male
Age:
Height:
feet
inches
R acial/E th n ic B ack g r ou n d
How would you best describe your racial/ethnic background?
African American
Middle Eastern
Asian and Pacific Islander
Native Indian
Caucasian
Other
Hispanic
Current Weight:
lbs.
Goal/Ideal Weight:
My goal is:
Gain weight: 1 lb a week
Gain weight: 2 lbs. a week
Lose weight: 1 lb. a week
Lose weight: 2 lbs. a week
Maintain weight
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lbs.
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My activity level is:
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Sedentary - little or no exercise, office job
Lightly active - light exercise/sports 1-3 days a week
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Moderately active - moderate exercise/sports 3-5 days a week
Very active - hard exercise/sports 6-7 days a week
Extremely active - hard daily exercise/sports & physical job
My fitness goal is:
Anaerobic fitness
Cardiovascular fitness
Heart healthy
Weight management
Female specific information:
Pregnant
Currently breast-feeding
1st Trimester
1st six months
2nd Trimester
2nd six months
3rd Trimester
Currently not breast-feeding
Not pregnant
General Health
1.1 Please complete the following statement:
"In General, my overall health is. . ."
Excellent
Very good
Good
Fair
Poor
Your Current Health
1.3 Have you ever been told you have any of the following diseases or illnesses?
Please indicate whether you are taking any medication for the health problem.
Stroke
1.3 A
Yes
Taking medication for health problem
No
Yes
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No
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Your Current Health continued
1.3 B Asthma
Yes
1.3 C Diabetes
Yes
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No
No
1.3 E
No
Yes
Yes
No
1.3 I
No
Yes
1.3 J
No
Yes
Yes
No
No
No
No
No
No
Taking medication for health problem
Yes
1.3 K Chronic bronchitis, COPD
Yes
No
Taking medication for health problem
High blood pressure
Yes
No
Taking medication for health problem
Cancer
Yes
No
Taking medication for health problem
1.3 H High cholesterol
Yes
No
Taking medication for health problem
1.3 G Osteoporosis
Yes
Yes
Taking medication for health problem
1.3 F Depression
Yes
No
Taking medication for health problem
Yes
No
Back pain
Yes
Yes
Taking medication for health problem
1.3 D Arthritis
Yes
Taking medication for health problem
No
Taking medication for health problem
Yes
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No
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Angina, congestive heart failure or heart attack
Yes
1.3 M Heartburn
Yes
1.3 N
1.3 P
No
Taking medication for health problem
Yes
No
No
Taking medication for health problem
No
Yes
Allergies
Yes
No
Yes
Anxiety
Yes
Yes
Taking medication for health problem
Headaches
Yes
1.3 O
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No
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No
Taking medication for health problem
No
Taking medication for health problem
No
Yes
No
Preventive Health
2.1 When was your last physical? (Leave blank if you can't remember.)
Month
Year
2.2 When was your last pap smear? (Leave blank if you can't remember.)
(If Male skip to question 2.10)
Month
Year
2.3 Have you ever had an abnormal pap smear? (If Male skip to question 2.11)
Yes
No
2.4 If you had an abnormal pap smear, did you follow up as recommended by your provider?
(If Male skip to question 2.10)
Yes
No
2.5 Have you had a HPV testing done in combination with your Pap smear in the last 5 years?
(Fill in only one.) (If Male skip to question 2.11)
Yes
No
Not sure
2.6 Do you take a folate supplement or multivitamin? (If Male skip to question 2.11)
Yes
No
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2.7 Have you ever had a mammogram?
(If Male skip to question 2.10)
Yes
No
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Not Applicable
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2.8 Date of last mammogram
(If Male skip to question 2.10)
Month
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Year
2.9 Do you have a mammogram performed yearly?
(If Male skip to question 2.10)
Yes
No
2.10 Do you receive at least 1200 mg/day of calcium?
(If Male skip to question 2.10)
Yes
No
Not sure
2.11 Have you ever had a colonoscopy?
Yes
No
2.12 Have you ever had a PSA test to screen for prostate cancer?
(If Female skip to question 2.12)
Yes
No
2.13 Have you had a flu shot in the last 12 months?
Yes
No
Nutrition
Breakfast
3.1 How often do you eat breakfast, more than just a roll and a cup of coffee?
Eat breakfast every day
Eat breakfast most mornings
Eat breakfast two or three times per week
Seldom or never eat breakfast
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Snacks
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3.2 How often do you eat snack foods between meals (chips, pastries, soft drinks,
candy, ice cream, cookies)?
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Three or more times per day
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Once or twice per day
Few times per week
Seldom or never eat typical snacks
Salt
3.3 How often do you add salt to your food or eat salty foods (chips, pickles, soy sauce)?
Seldom or never
Some meals
Most meals
Nearly every meal
Fat Intake
3.4 Indicate the foods you usually eat.
High-Fat Examples
Low-Fat Examples
Hamburgers
Hot dogs
Bologna
Steaks
Sour cream
Cheese
Whole milk
Eggs
Butter
Cake
Pastry
Ice cream
Chocolate
Fried foods
Many fast foods
Lean meats
Skinless poultry
Fish
Skim milk
Low-fat dairy products
Fruit desserts
Gelatin
Vegetables
Pasta
Legumes (peas and beans)
Nearly always eat high-fat foods
Eat mostly high-fat foods, some low-fat
Eat both about the same
Eat mostly low-fat foods, some high-fat
Eat only low-fat foods
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Breads and Grains
Refined-Grain Examples
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White bread
White rolls
Regular pancakes/waffles
White rice
Typical breakfast cereals
Typical baked goods
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3.5 Indicate the kinds of breads and grains you usually eat.
Whole-Grain Examples
Whole-grain breads
Brown rice
Oatmeal and many other cooked cereals
Whole-grain or high-fiber cereals
Nearly always eat refined grain products
Eat mostly refined grain products, some whole-grain
Eat both about the same
Eat primarily whole-grain products, some refined
Eat only whole-grain products
Fruits and Vegetables
3.6 How many servings of fruits or vegetables do you eat daily?
(One serving = 1 cup fresh, 1/2 cup cooked, 1 medium size fruit or 3/4 cup juice).
One or less
Two daily
Three daily
Four daily
Five or more daily
Sweets and Desserts
3.7 How many servings of cookies, cakes, donuts, candy, soda, or packets of sugar do
you eat daily?
One or less
Two daily
Three daily
Four daily
Five or more daily
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Physical Activity
4.1 How many days per week do you participate in at least 20 to 30 minutes of physical
activity?
Moderate = Brisk walk, enough to break a light sweat, but with out becoming winded.
Vigorous = Running, enough to break a heavy sweat and experience heavy breathing.
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None
One day of moderate exercise
Two days of moderate exercise
Three days of moderate OR 1 day of vigorous exercise
Four days of moderate OR 2 days of vigorous exercise
Five days of moderate OR 3 days of vigorous exercise
Six days of moderate OR 4 days of vigorous exercise
Seven days of moderate OR more than 4 days of vigorous exercise
Strength Exercises
4.2 How many days per week do you engage in strength training exercises?
None
Once a week
Twice a week
Three or more times a week
Stretching Exercises
4.3 How many times per week do you do stretching exercises to improve the flexibility
of your back, neck, shoulders, and legs?
None
Once a week
Twice a week
Three or more times a week
Emotional Health
5.1 During the last 2 weeks, has feeling down, depressed or hopeless bothered you?
Yes
No
5.2 During the last 2 weeks, has little interest or little pleasure in doing things bothered you?
Yes
No
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Emotional Health - continued
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5.3 Do you have a history of depression?
Yes
No
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5.4 In the last six months, have you thought about hurting yourself?
Yes
No
5.5 Do you have a suicide plan?
Yes
No
If you answered yes to questions 5.3, 5.4 or 5.5 regarding suicide and depression, it is
urgent that you seek immediate medical treatment for depression/anxiety. You may call you
local health care provider, 911, or the National Suicide Prevention Lifeline at 1 (800)
273-TALK (8255) or http://www.suicidepreventionlifeline.org.
Emotional Problems
5.6 In the past month, have you felt any of the following? (Select all that apply.)
Downhearted or sad
Angry or hostile
Nervous or uptight
That you are receiving good support from friends and family
That interesting and challenging situations fill your life
Social Activity
5.7 During the past four weeks, to what extent has your physical health or an emotional
problem interfered with your normal activities with family, friends, neighbors, or groups?
None at all
Slightly
Moderately
Quite a bit
Coping Status
5.8 How well do you feel you are coping with your current stress load?
Coping very well
Coping fairly well
Have trouble coping at times
Often have trouble coping
Feel unable to cope
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Extremely
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Coping Status - continued
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5.9 Do you have good support from your family and friends?
Yes
No
5.10 During the past year have you had any major life or work changes?
Yes
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No
Stress Signals
5.11 Select any item below that applies to you: (Select all that apply.)
Minor problems throw me for a loop
I find it dificult to get along with people
Nothing seems to give me pleasure anymore
I am unable to stop thinking about my problems
I feel frustrated, impatient, or angry much of the time
I feel tense or anxious much of the time
5.12 Stress reduction techniques (things like exercise, reading, journaling, drawing,
mediation, etc) are useful in managing daily stress. How often do you incorporate
stress reduction techniques into your week? (Fill in only one.)
Daily
Most days
Few days
Never
Sleep
5.13 How often do you get seven to eight hours of sleep per night? (Fill in only one.)
Always
Most of the time
Less than half the time
Seldom or never
Less than half the time
Seldom or never
Automotive
6.1 Do you wear a seatbelt in the car?
Yes
No
6.2 How often do you wear a seatbelt?
Always
Most of the time
Home
6.3 Do you have a smoke detector in your home?
Yes
No
Not sure
6.4 Do you have a carbon monoxide detector in your home?
Yes
No
Not sure
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Self
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6.5 Do you regularly apply sunscreen of SPF 15 or greater?
Yes
No
Sometimes
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6.6 Within the last 12 months, have you been in a relationship in which threats, pushing,
grabbing, hitting, kicking, breaking things or other harmful behavior was used?
Yes
Smoking Status
No
7.1 Select the appropriate response:
Have never smoked
Quit smoking two or more years ago
Quit smoking one or two years ago
Quit smoking 6-12 months ago
Currently smoke a pipe or cigar only
Currently smoke less than 10 cigarettes daily
Currently smoke 10 or more cigarettes daily
Chewing Tobacco
7.2 Do you use chewing tobacco?
Yes
No
Alcohol
Number of Drinks
8.1 How many alcoholic drinks do you usually consume each week?
(One drink = a 12 oz. beer or wine cooler, 5 oz. wine, or 1.5 oz. distilled liquor)
0
1 to 7
8 to 14
15 to 20
21 or more
8.2 Have you had 5 or more alcoholic drinks in a single sitting in the last 6 months?
Yes
No
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Drinking and Driving
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8.3 Do you sometimes drive when perhaps you've had too much to drink or do you
ever ride with a person who has been drinking?
Yes
No
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Medications and Drugs
8.4 How often do you use drugs or medications (include prescription and non-prescription)
that affect your mood, help you relax, or help you sleep? (This question is intended to
assess those that are taking medications OTHER THAN daily use medications for the
treatment of depression, anxiety, or other mental health conditions.)
Frequently
Sometimes
Rarely
Never
Indicate how ready you are to make changes or improvements in your health in the
following ways:
9.1 Be physically active most days.
Haven't thought about changing
Plan a change in the next 6 months
Plan to change this month
Recently started doing this
Do this regularly (last 6 months)
9.2 Eat mostly healthy foods.
Haven't thought about changing
Plan a change in the next 6 months
Plan to change this month
Recently started doing this
Do this regularly (last 6 months)
9.3 Live smoke and tobacco free.
Haven't thought about changing
Plan a change in the next 6 months
Plan to change this month
Recently started doing this
Do this regularly (last 6 months)
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9.4 Achieve/maintain healthy weight.
Plan a change in the next 6 months
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Plan to change this month
Recently started doing this
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Haven't thought about changing
Do this regularly (last 6 months)
9.5 Handle stress well.
Haven't thought about changing
Plan a change in the next 6 months
Plan to change this month
Recently started doing this
Do this regularly (last 6 months)
9.6 Live an overall healthy lifestyle.
Haven't thought about changing
Plan a change in the next 6 months
Plan to change this month
Recently started doing this
Do this regularly (last 6 months)
Biometrics
Providing your biometric data will help us to further assess your health. If you have
recently completed an on-site health screening or have had your physician complete
your health screening, please enter the results below. If you do not have current data
available, please enter the most recent data you have or leave it blank.
Current Weight:
lbs.
Blood Pressure:
Systolic (mmHg)
(Top number)
Blood Glucose:
(mg/dL)
Total Cholesterol:
(mg/dL)
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Diastolic (mmHg)
(Bottom number)
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HDL (good) Cholesterol:
(mg/dL)
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LDL (bad) Cholesterol:
Triglycerides:
(mg/dL)
(mg/dL)
2012 Health Assessment Supplemental Survey
Please answer all applicable questions. Thank You!
11.1 Physical Activity - Compared to one year ago, how would you rate your physical
health in general now?
Much better
Slightly better
About the same
Slightly worse
Much worse
11.2 Physical Activity - In the past 12 months, did you talk with a doctor or other health
provider about your level of exercise or physical activity? For example, a doctor or
other health provider may ask if you exercise regularly or take part in physical exercise.
Yes
No
I had no visits in the past 12 months
11.3 Mental Health -Compared to one year ago, how would you rate your emotional
problems (such as feeling anxious, depressed or irritable) in general now?
Much better
Slightly better
About the same
Slightly worse
Much worse
11.4 Incontinence - Many people experience problems with urinary incontinence, the
leakage of urine. In the past 6 months, have you accidentally leaked urine?
Yes
No
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11.5 Incontinence - If yes to above, have you talked to your current doctor or other
health provider about your urine leakage problem?
Yes
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No
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11.6 Fall Prevention - In the past 12 months, have you had a problem with balance or
walking?
Yes
No
11.7 Fall Prevention - In the past 12 months, has your doctor or other heath provider
done anything to help prevent falls or treat problems with balance or walking? Some
things they might do include: suggest that you use a cane or walker, check your
blood pressure lying or standing, suggest that you do an exercise or physical therapy
program or suggest a vision or hearing test.
Yes
No
I had no visits in the past 12 months
11.8 Osteoporosis - Have you ever had a bone density test to check for osteoporosis,
sometimes thought of as "brittle bones?" This test may have been done to your
back, hip, waist, heel or finger.
Yes
No
Thank You for participating!
You'll receive your Health Assessment Report within 30 days.
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