Health Risk Assessment

This Health Appraisal is a voluntary offering by your employer designed to help deepen their knowledge about their employee’s health status and make important improvements where needed.

Agreement to Participate:
Completing this appraisal voluntary and there is no requirement to participate.

Information Usage:
Your employer will receive an aggregate report at the completion of the intake process that includes only high-level information (ie: 50% of participants are a healthy weight). Your employer will not receive any personal health information or individual results.

This Health Appraisal Program prevents improper disclosure of information by complying with the HIPAA Privacy and Protected Health Information (PHI) requirements as outlined in the Medical Associates Compliance Plan.

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* 1. Contact Information

Name

Cutomer ID

Address

City/Town

State/Province

ZIP/Postal Code

Date of Birth

Email Address

Phone Number

General Questions

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* 2. What is your height in feet and inches? For example, if you are 5 feet and 4 inches, write 5’4”.

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* 3. What is your weight? (pounds)

Under 100

100-125

126-150

151-175

176-200

201-225

Over 226

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* 4. In general, how would you rate your health?

Excellent

Very Good

Good

Fair

Poor

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* 5. What conditions do you have, or have had in the past? (Please indicate all that apply.)

Anxiety

Asthma

Bipolar Disorder

Cancer

COPD/emphysema

Coronary heart disease

Dementia

Depression

Diabetes

Hearing problems

Heart Failure

Hypertension

Organ transplant

Renal/kidney failure

Schizophrenia

Vision problems

Other (please specify)

None of the above

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* 6. Which of the following are you currently receiving treatment for? (Please indicate all that apply)

Anxiety

Asthma

Bipolar Disorder

Cancer

COPD/emphysema

Coronary heart disease

Dementia

Depression

Diabetes

Hearing problems

Heart Failure

Hypertension

Organ transplant

Renal/kidney failure

Schizophrenia

Vision problems

Other (please specify)

None of the above

General Health

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* 7. I use tobacco products (cigarettes, smokeless tobacco, cigars and pipes).

Never

Rarely

Sometimes

Usually

Always

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* 8. I limit my number of alcoholic drinks ( beer, liquor, wine) to ( per week) 5 for men and 4 for women.

Never

Rarely

Sometimes

Usually

Always

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* 9. I visit my dentist every six months for regular check-ups.

Never

Rarely

Sometimes

Usually

Always

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* 10. I see my physician for routine check-ups, health screenings, and disease prevention.

Never

Rarely

Sometimes

Usually

Always

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* 11. I protect my skin from sun damage by using sunscreen, wearing hats, and/or avoiding tanning booths and sunlamps.

Never

Rarely

Sometimes

Usually

Always

Physical Activity

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* 12. I engage in moderate physical activity outside of work for at least 20 to 30 minutes at least 5 days of the week.

Never

Rarely

Sometimes

Usually

Always

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* 13. When I do physical activity it includes a variety such as stretching, aerobic activity, and strength conditioning.

Never

Rarely

Sometimes

Usually

Always

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* 14. I use alternative modes of transportation whenever possible to and from various locations. (i.e. stairs instead of elevator, walking or biking instead of driving)

Never

Rarely

Sometimes

Usually

Always

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* 15. I take the health benefits of physical activities and their lasting impact seriously.

Never

Rarely

Sometimes

Usually

Always

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* 16. I enjoy doing physical activities rather than sedentary activities.

Never

Rarely

Sometimes

Usually

Always

Nutrition

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* 17. I eat at least three servings of fruits and vegetables every day (one serving equals one half cup).

Never

Rarely

Sometimes

Usually

Always

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* 18. I include foods that are high in fiber in my diet on a daily basis (i.e. whole grain breads and cereals, beans, etc.).

Never

Rarely

Sometimes

Usually

Always

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* 19. I avoid eating foods that are high in fat such as whole milk, fried foods, fatty meats, etc.

Never

Rarely

Sometimes

Usually

Always

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* 20. I eat at fast food restaurants less than three times per week.

Never

Rarely

Sometimes

Usually

Always

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* 21. I maintain a healthy weight within the recommendations specified by a health care professional.

Never

Rarely

Sometimes

Usually

Always

Safety

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* 22. I wear a seat belt when traveling in a vehicle.

Never

Rarely

Sometimes

Usually

Always

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* 23. I stay within five miles per hour of the speed limit.

Never

Rarely

Sometimes

Usually

Always

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* 24. I feel safe in my home.

Never

Rarely

Sometimes

Usually

Always

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* 25. I am able to perform everyday activities such as eating, getting dressed, grooming, bathing, walking, or using the toilet without assistance.

Never

Rarely

Sometimes

Usually

Always

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* 26. I take the proper precautions to avoid or reduce accidents at home.

Never

Rarely

Sometimes

Usually

Always

Social and Environmental Wellness

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* 27. I have access to reliable transportation to get me to the places I need or want to go.

Never

Rarely

Sometimes

Usually

Always

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* 28. Access to adequate food, clothing, utilities, and housing is a concern for me.

Never

Rarely

Sometimes

Usually

Always

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* 29. I take time to have meaningful interactions with family and friends.

Never

Rarely

Sometimes

Usually

Always

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* 30. I contribute time and/or money to my community, church or other interests that I have.

Never

Rarely

Sometimes

Usually

Always

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* 31. I get the social support I need from family and friends.

Never

Rarely

Sometimes

Usually

Always

Emotional Awareness

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* 32. My relationship and behaviors are maintained in a manner which is healthy for me and for others.

Never

Rarely

Sometimes

Usually

Always

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* 33. I am able to develop close, personal relationships with others.

Never

Rarely

Sometimes

Usually

Always

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* 34. I have positive relationships with both men and women in my life.

Never

Rarely

Sometimes

Usually

Always

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* 35. I feel that I am a confident individual.

Never

Rarely

Sometimes

Usually

Always

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* 36. I am able to respect others for who they are, regardless of race, gender, age attitude, and interests.

Never

Rarely

Sometimes

Usually

Always

Mental Wellness

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* 37. I express my feelings of anger and frustration in ways that are not hurtful to myself or others.

Never

Rarely

Sometimes

Usually

Always

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* 38. I feel down, depressed, or hopeless.

Never

Rarely

Sometimes

Usually

Always

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* 39. I rely on drugs or other medications (other than exactly as prescribed for you) to help me to relax or improve my mood.

Never

Rarely

Sometimes

Usually

Always

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* 40. I feel that I have family and friends that I can confide in to assist in managing stress.

Never

Rarely

Sometimes

Usually

Always

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* 41. I take responsibility for my actions and understand the effects that they have on others.

Never

Rarely

Sometimes

Usually

Always

Values, Spirituality, and Beliefs

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* 42. I feel that my life has purpose.

Never

Rarely

Sometimes

Usually

Always

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* 43. I am able to discuss my values and beliefs with my family and friends in a reasonable manner.

Never

Rarely

Sometimes

Usually

Always

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* 44. My actions are guided by my own beliefs rather than the beliefs of others.

Never

Rarely

Sometimes

Usually

Always

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* 45. I spend a portion of every day in personal reflection.

Never

Rarely

Sometimes

Usually

Always

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* 46. I am tolerant of the values and beliefs of others.

Never

Rarely

Sometimes

Usually

Always

Preventative Health

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* 47. Do you get a flu vaccine each year?

Yes

I don't know

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* 48. Have you ever had one or more pneumonia shots (also called Pneumococcal vaccine)?

Yes

I don't know

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* 49. When was the last time you had a Breast cancer screening (mammogram)?

In the last year

In the last 2-4 years

In the last 5 years

In the last 10 years

Never

Not Applicable

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* 50. When was the last time you had a Colorectal cancer screening (colonoscopy)?

In the last year

In the last 2-4 years

In the last 5 years

In the last 10 years

Never

Not Applicable

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* 51. When was the last time you had a Cervical cancer screening (PAP smear)?

In the last year

In the last 2-4 years

In the last 5 years

In the last 10 years

Never

Not Applicable

Readiness to Change

Your Healthy Behavior

Small everyday changes can have a big impact on your health. Think about the changes you would be most interested in making over the next year.

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* 52. Thinking about your health behavior, do you want to make some small lifestyle changes in this area to improve your health?

Yes, I know the changes I want to make

I want to learn more about the changes I can make

I don't want to make a change right now

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 53. How much support do you think you would get from family and friends if they knew you were trying to make some changes?

Yes, I think my family or friends would help me

I think I have some support

I don't think my family of friends would help me

Clear

i We adjusted the number you entered based on the slider’s scale.

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* 54. How much support would you like from your health care provider or health plan to make these changes?

Yes, I am interested in signing up for programs that can help me

I want to learn more about programs that can help me

I do not want to be contacted

Clear

i We adjusted the number you entered based on the slider’s scale.