Health Risk Assessment Form – Fill Out and Use

1.

In general, would you say your health is:

(circle one number)

1

2

3

4

5

1 - Excellent

2 - Very Good 3 - Good 4 - Fair 5 - Poor

The following are activities you might do during a normal day. Please circle one of the numbers to describe

how much your health limits you in any of these activities.

1 - Yes, limited a lot

2 - Yes, limited a little

3 - No, not limited

(circle one number on each line)

2.

Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf.

1

2

3

1

2

3

3.

Climbing several flights of stairs.

During the past 4 weeks, have you had any of the following problems with your work or daily activities as a

result of your physical health?

q Yes

q No

4.

Could not get done as much as I would like.

q Yes

q No

5.

Was limited in the kind of work or other activities.

During the past 4 weeks, have you had any of the following problems with your work or daily activities as a

result of any emotional problems (such as feeling depressed or anxious)?

q Yes

q No

6.

Could not get done as much as I would like.

q Yes

q No

7.

Did not do work or other activities as carefully as usual.

8. During the past 4 weeks, how much did pain get in the way of your normal work (including both work

outside the home and housework)?

1

2

3

4

5

1 - Not at all

2 - Slightly 3 - Moderately

4 - Quite a bit 5 - Extremely

(circle one number)

These questions are about how you feel and how things have been with you during the past 4 weeks. For

each question, please give the one answer that comes closest to the way you have been feeling.

1 - All of the time

2 - Most of the time 3 - A good bit of the time

4 - Some

5 - A little of the time 6 - None of the time

During the past 4 weeks, how often: (circle one number on each line)

9.

Have you felt calm and peaceful?

1

2

3

4

5

6

10.

Did you have a lot of energy?

1

2

3

4

5

6

11.

Have you felt sad or down?

1

2

3

4

5

6

12.

During the past 4 weeks, how often has your physical health or emotional problems gotten in the way of

1

2

3

4

5

6

your social activities (such as visiting with friends, relatives, etc.)?

q Yes

q No

13.

Have you seen a psychiatrist or any other mental/emotional health provider previously?

q Yes

q No

14.

Have you ever been in a psychiatric facility?

q Yes

q No

15.

Are you on any behavioral health medicines?

If yes, what are they? _____________________________________

q Yes

q No

16.

Have you ever been treated for substance abuse (alcohol, drugs)?

q Yes

q No

17.

Do you need help getting a counselor, therapist, or psychiatrist?

q Yes

q No

18.

Do you need help getting food, clothing or housing?

q Yes

q No

a.

Congestive heart failure

q Yes

q No

b.

Chronic lung disease (including bronchitis, emphysema or COPD)

q Yes

q No

c.

Diabetes Mellitus (sugar diabetes)

q Yes q No

d.

Asthma

q Yes

q No

e.

Sickle Cell

q Yes

q No

f.

HIV/AIDS

q Yes

q No

g.

Hypertension (high blood pressure)

q Yes

q No

h.

Heart attack

q Yes

q No

i.

Stroke

q Yes

q No

j.

End stage kidney disease requiring dialysis

q Yes q No

k.

Cancer

q Yes

q No

l.

Autoimmune disorders (rheumatoid arthritis, lupus, multiple sclerosis)

q Yes q No

m.

Dementia

q Yes

q No

n.

End stage liver disease

q Yes

q No

o.

Blood disorders, clotting disorders

q Yes

q No

p.

Neurologic disorders

q Yes

q No

q.

Cardiovascular disorders

q Yes

q No

r.

Chronic mental health conditions

q Yes q No

s.

Smoker’s cough

q Yes

q No

t.

Chronic kidney disease

q Yes

q No

20.

Compared to one year ago, my health in general is much worse.

Section Two: Preventive Health

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2

3

1.

How would you describe your smoking habits?

1

- Still smoke

2

- Used to smoke

3

- Never smoked

1

2

3

4

2.

How long has it been since your last tetanus shot?

1

– Within the last year

2

– Within the last 10 years

3

– More than 10 years ago

4

– Do not know

1

2

3

4

3.

How long has it been since your last flu shot?

1

– Within the last 6 months

2

– Within the last year

3

– Do not know

4

– Never