University of Michigan Health Management Research Center

Health Risk Appraisal Questionnaire

The questionnaire below is only a sample for demonstration purposes. Any answers provided will not be processed for the generation of a personal report.

Email
If possible, please provide an email address. It is used only for infrequent communication regarding this Health Risk Appraisal, such as HRA Password reminders.
Name
Address
City State Zip

Complete each question as best you can, by indicating the best response. Your participation in this questionnaire is voluntary. However, to receive the most benefit from your report, please answer all questions.

Your results will be kept strictly confidential.

 1 Identification Number Confirmed
 2 Gender
 3 Age (at last birthday)
 4 If Yes, complete questionnaire based on your health condition and lifestyle before pregnancy.
 5 Height (without shoes) OR
 6 (without shoes)
 7
 8 What is your blood pressure now?

 9 (based on a blood test)
10 (based on a blood test)

       HEALTH-RELATED BEHAVIORS

11 CIGARETTE SMOKING
How would you describe your cigarette smoking habits?
, Go to question 12
, Go to question 13
, Go to question 14
12 Still Smoke Go to question 14
13 Used to Smoke
How many years has it been since you smoked cigarettes on a fairly regular basis?
14 OTHER FORMS OF TOBACCO
Do you smoke or use


15
16 How many drinks of alcoholic beverages do you have in a typical week?
(one drink = one beer, glass of wine, shot of liquor or mixed drink)
17 How many times in the last month did you drive or ride when the driver had perhaps too much to drink?
18 In the next 12 months, how many miles will you probably drive or ride in each of the following?
19
20
21
22
23
24
25
26
27

       QUALITY-OF-LIFE INDICATORS

28
29
30
31
32
33
34

       MEDICAL HISTORY AND SELF-CARE

35 Do you have:
36 When was the last time you had these preventive services or health screenings?





for Women Only

for Men Only
37 In the past 12 months, how many times have you:

       Women (Men go to question 42)

38
39
40
41

       Men (Women go to question 43)

42

       PERSONAL INFORMATION

43
44
45
46

       HEALTH PLANNING QUESTIONS

47 In the next 6 months, are you planning to make any changes to keep yourself healthy or improve your health?






48
49

       CURRENTLY EMPLOYED ONLY

50
51
52
53 How many hours did you take off from work over the past 2 weeks to take care of sick children, adults or elders? (This might include taking children to doctor appointments, staying home with a sick child or parent, or calling doctors or health insurance companies.)

54 About how many hours altogether did you work in the past 7 days? (If more than 97, enter 97.) hours
55 How many hours does your employer expect you to work in a typical 7-day week? (If it varies, estimate the average. If more than 97, enter 97.) hours
56 Now please think of your work experiences over the past 4 weeks (28 days). In the spaces provided below, enter the number of days you spent in each of the following work situations.
In the past 4 weeks (28 days), how many days did you ...
 
a. ... miss an entire work day because of problems with your physical or mental health? (Please include only days missed for your own health, not someone else's health.)
b. ... miss an entire work day for any other reason (including vacation)?
c. ... miss part of a work day because of problems with your physical or mental health? (Please include only days missed for your own health, not someone else's health.)
d. ... miss part of a work day for any other reason (including vacation)?
e. ... come in early, go home late, or work on your day off?
57 About how many hours altogether did you work in the past 4 weeks (28 days)? (Example: 40 hours per week for 4 weeks = 160 hours) hours
58
59
60

Apr 16, 2014; 21:05:18 EDT Problems: problems@www.hmrc.kines.umich.edu