The HEALTHIER PEOPLE NETWORK, Inc.
To receive the HPN Health Risk Appraisal computer program,
please send this form and your check or purchase order for
$195.00 to the above address.
Thank you for your interest
in the health of our nation.
__________________________________________________________ ________
Name of person responsible for using HRA V6 Degree
____________________________________________________________________
Professional Discipline
__________________________________________________________________
__
Department
_____________________________________________________________________
Organization
_____________________________________________________________________
Address: Street
S:uite/Room
________________________________________ ___ ___ ___ ___ ___ ___ ___
City State Zip
Telephone:(____)-____________
Fax:____(____)-____________
e-mail:_____________________________________
Your responses to the following items will help us to better meet your
needs for using the Health Risk Appraisal program.
1. The setting in which the HRA will be used: 2. The population you expect to serve:
business_______
(check all that apply)
church________
___male
clinic ________
___female
college/university________
ages: ___18-25
health care office________
___25-65:
health fair________
___65-90
hospital______
research cente_______
3. If
non-English speaking, specify
senior center________
language: _______________
otherspecify________
4. How will the HRA be administered? individually____ in a group____
5. How many HRA’s do you expect to administer in the next year? ______
6. Which HRA(s) do you expect to use? Midlife Adult____ Older Adult____
