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IDENTIFICATION NUMBER
The health risk appraisal is an educational tool, showing you choices you can make to keep
good health and avoid the most common causes of death (for a person of your age and sex).
This health risk appraisal is not a substitute for a check-up or physical
exam that you get from a doctor or nurse; however, it does provide some ideas for lowering your risk of getting sick or injured
in the future. It is NOT designed for people who already have HEART DISEASE,
CANCER, KIDNEY DISEASE, OR OTHER SERIOUS CONDITIONS; if you have any of these problems, please ask your health care provider
to interpret the report for you.
DIRECTIONS:
To get the most accurate results, answer
as many questions as you can. If you do not know the answer leave it blank.
The following
questions must be completed or the computer program cannot process your questionnaire:
1. SEX 2. AGE 3. HEIGHT 4. WEIGHT
15. CIGARETTE SMOKING
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Please write your answers in the boxes
provided.
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1. SEX
Þ |
1 o
Male
2 o Female |
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2. AGE |
________Years |
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3. HEIGHT (Without shoes)
(No fractions) |
___Feet___Inches |
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4. WEIGHT (Withoutshoes) (No fractions) |
__________Pounds |
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5. Body frame size |
1 o Small
2 o Medium
3 o Large |
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6. Have you ever
been told that you have diabetes (or sugar diabetes)? |
1 o Yes 2 o No
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7. Are you now
taking medicine for high blood pressure? |
1 o Yes 2 o No
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8. What is your
blood pressure now? |
__Systolic(HighNo.)
__Diastolic (LowNo.) |
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9. If you do not know the numbers, check the box that describes your blood pressure. |
1 o High
2 o Normal or Low
3 o Don't Know |
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10. What is your TOTAL cholesterol
level (based on a blood test)? |
_______mg/dl |
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11. What is your HDL cholesterol
(based on a blood test)? |
______ mg/dl |
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12. How many cigars do you
usually smoke per day? |
_____cigars per day |
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13. How many pipes of tobacco
do you usually smoke per day? |
_____pipes per day |
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14. How many times per day
do you usually use smokeless tobacco?
(Chewing
tobacco, snuff, pouches, etc.) |
_____times per day |
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15. CIGARETTE SMOKING
How
would you describe your cigarette smoking habits?
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1 o Never smoked
* Go to 18
2 o Used to smoke
* Go to 17
3 o Still smoke
* Go to 16 |
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16. STILL SMOKE
How many cigarettes a day do you smoke?
* GO TO QUESTION
18 |
_____cigarettes
per day
* Go
to 18 |
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17. USED TO SMOKE
a. How many years has it been since you smoked cigarettes fairly regularly?
b. What was the average number of cigarettes per day that you smoked in the 2 years before you quit? |
__ years
__cigarettes per day |
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18. In the next 12 months, how many
thousands of miles will you probably travel by each of the following?
(NOTE: U.S. average = 10,000 miles)
a. Car, truck, or van:
b. Motorcycle: |
_____ ,000 miles
_____ ,000 miles |
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19. On a typical day, how do
you USUALLY travel? (Check one only) |
1 o Walk
2 o Bicycle
3 o Motorcycle
4 o Sub-compact or compact car
5 o
Mid-size or full-size car
6 o Truck or van
7 o Bus, subway,
or train
8 o Mostly stay home |
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20. What percent of time do
you usually buckle your safety belt when driving or riding? |
_____ % |
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21. On the average, how close
to the speed limit do you usually drive? |
1 o Within 5 mph of limit
2 o 6-10 mph over limit
3 o 11-15 mph over limit
4 o More than 15 mph over limit
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22.
How many times in the last month did you drive or ride when the driver had perhaps too much alcohol to drink? |
___times last month |
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23. How many drinks of an alcoholic
beverage do you have in a typical week?
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(Write the
number of each type of drink)
___Bottles or cans of beer
___Glasses of wine
___Wine coolers
___Mixed drinks or shots of liquor |
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WOMEN ONLY
24. At what age did you have your first menstrual period? |
____years old |
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25. How old were you when your
first child was born? |
____years old
(If no children, write 0) |
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26. How long has it been since
your last breast x-ray (mammogram)? |
1 o Less than 1 year ago
2 o 1 year ago
3 o 2 years ago
4 o 3 or more years ago
5 o Never |
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27. How many women in your
natural family (mother and sisters only) have had breast cancer? |
_____Women |
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28. Have you had a hysterectomy
operation? |
1 o Yes
2 o No
3 o Not sure |
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29. How long has it been since
you had a pap smear test? |
1 o Less than 1 year ago
2 o 1 year ago
3 o 2 years ago
4 o 3 or more years ago
5 o Never |
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H30. How often do you examine your breasts for lumps? |
1 o Monthly
2 o Once every few months
3 o Rarely or never |
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H31. About how long has it been since you had your breasts examined by
a physician or nurse? |
1 o Less than 1 year ago
2 o 1 year ago
3 o 2 years ago
4 o 3 or more years ago
5 o Never |
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H32. About how long has it been since you had a rectal exam?
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1 o Less than 1 year ago
2 o 1 year ago
3 o 2 years ago
4 o 3 or more years ago
5 o Never |
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MEN ONLY
H33. About how long has it been since you had a rectal or prostate exam?
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1 o Less than 1 year ago
2 o 1 year ago
3 o 2 years ago
4 o 3 or more years ago
5 o Never |
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H34. How many times in the last year did you witness or become involved
in a violent fight or attack where there was a good chance of a serious injury to someone? |
1 o 4 or more times
2 o 2 or 3 times
3 o 1 time or never
4 o Not sure |
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H35. Considering your age, how would you describe your overall physical
health? |
1 o Excellent
2 o Good
3 o Fair
4 o Poor |
H36. In an average week, how many times do you engage in physical activity (exercise or work which lasts at least 20 minutes without stopping and which is hard enough to
make you breathe heavier and your heart beat faster)?
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1 o Less than 1 time per week
2 o 1 or 2 times per week
3 o At least 3 times per week |
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H37. If you ride a motorcycle or all-terrain vehicle (ATV), what percent
of the time do you wear a helmet? |
1 o 75% to 100%
2 o 25% to 74 %
3 o Less than 25%
4 o Does not apply to me |
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H38. Do you eat some food every day that is high in fiber, such as whole
grain bread, cereal, fresh fruits or vegetables? |
1 o Yes 2 o
No |
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H39. Do you eat foods every day that are high in cholesterol or fat, such
as fatty meat, cheese, fried foods, or eggs? |
1 o Yes 2 o
No |
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H40. In general, how satisfied are you with your life? |
1 o Mostly satisfied
2 o Partly satisfied
3 o Not satisfied |
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H41.
Have you suffered a personal loss or misfortune in the past year
that had a serious impact on your life? (For example, a job loss, disability,
separation, jail term, or the death of someone close to you.) |
1 o Yes, 1 serious loss or misfortune
2 o Yes, 2 or more
3 o No |
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H42a. Race |
1 o Aleutian, Alaska native, Eskimo or American Indian
2 o Asian
3 o Black
4 o Pacific Islander
5 o White
6 o Other
7 o Don't know |
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H42b. Are you of Hispanic origin, such as Mexican-American, Puerto Rican, or Cuban? |
1 o Yes
2 o No |
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H43. What is the highest grade you completed in school? |
1 o Grade school or less
2 o Some high school
3 o High school graduate
4 o Some college
5 o College graduate
6 o Post graduate or professional degree |
