HEALTH RISK ASSESSMENT (HRA) Question Title 1. Patient Name: Question Title 2. Date of Birth: Question Title 3. Employer Cass County Government City of Logansport Question Title 4. Mark all of the following that you are being treated for, taking medication for or have been diagnosed with: Depression/Anxiety Cancer Hyperlipidemia (High Cholesterol) Hypertension (High Blood Pressure) Heart Disease Diabetes Lung Disease/COPD/Asthma Other None of the above Question Title 5. Number of prescribed and/or over-the-counter medications you currently take Question Title 6. In general, how would you rate your health? Excellent Very Good Good Fair Poor Question Title 7. In general, how many days do you get at least 30 minutes of exercise each week? 1 day 2 days 3 days 4 days 5 days 6 days 7 days Question Title 8. Do you plan to increase your exercise in the next 3 months? No plans to increase exercise in the next 3 months. Thinking about increasing exercise in the next 3 months. Making plans or currently working on increasing exercise. Question Title 9. In general, how many servings of fruits and vegetables do you get in a typical day? None 1 serving 2 servings 3 servings 4 servings 5+ servings Question Title 10. Do you have plans to increase your fruits and vegetables in the next 3 months? No plans to increase fruits and vegetables in the next 3 months. Thinking about increasing fruits and vegetables in the next 3 months. Making plans or currently working on increasing fruits and vegetables. Question Title 11. Do you use tobacco products? No, not ever No, I quit Yes, smoking tobacco (includes pipe tobacco). Yes, chewing tobacco. Question Title 12. Current/Former Smokers: Number of Packs/Day Number of Years Number of Chews/Day Number of Years Question Title 13. How many cups of coffee or caffeinated beverages do you normally consume daily? 0 1-3 4-6 7 or more Question Title 14. How many 8 ounce glasses of water do you normally drink daily? 0-2 3-5 6-8 9+ Question Title 15. Do you consume alcohol? Yes No Question Title 16. How many drinks per week? 0-2 3-5 5-9 More than 10 Question Title 17. How often do you feel stress in your life? Seldom stressed. Sometime stressed. Often stressed. Very often stressed. Question Title 18. What do you consider the main source of your stress? Health Family Work Financial Friends Relationship issues/status Other Question Title 19. During the past year, how often have you felt tense, anxious or depressed? Every day Almost every day Occasionally Never Question Title 20. How many hours of sleep do you get each night? Less than 4 4-5 hours 6-7 hours 8+ hours Question Title 21. Do you have any of the following symptoms? Periods of stopped breathing during sleep Snorting and gasping during sleep Shortness of breath during sleep that is relieved when sitting up Wake unrefreshed from sleep Daytime sleepiness None of the above Done