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
Yes
No
Does not apply
If Yes, complete questionnaire based on your health condition and lifestyle before pregnancy.
 5 Height (without shoes) OR
 6 (without shoes)
pounds
kilograms
 7
inches
centimeters
 8 What is your blood pressure now?

 9 (based on a blood test)
mg/dL
mmol/L

10 (based on a blood test)
mg/dL
mmol/L

       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?

less than 9
10 - 15
16 - 19
20+
14 OTHER FORMS OF TOBACCO
Do you smoke or use

Yes
No


Yes
No


Yes
No
15
Almost every day
Sometimes
Rarely or never
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?

1 - 1,999 miles (1 - 3,199 km)
2,000 - 4,999 miles (3,200 - 7,999 km)
5,000 - 9,999 miles (8,000 - 16,099 km)
10,000 - 14,999 miles (16,100 - 24,099 km)
15,000 - 19,999 miles (24,100 - 32,199 km)
20,000 - 29,999 miles (32,200 - 48,299 km)
30,000 miles (48,300 km) or more
Do not drive or ride

1 - 999 miles (1 - 1,599 km)
1,000 - 1,999 miles (1,600 - 3,199 km)
2,000 - 2,999 miles (3,200 - 4,799 km)
3,000 - 3,999 miles (4,800 - 6,399 km)
4,000 - 4,999 miles (6,400 - 7,999 km)
5,000 miles (8,000 km) or more
Do not drive or ride
19
100%
90 - 99%
80 - 89%
less than 80%
20
Within 5 mph (8 km/h) of the speed limit
6 - 10 mph (9 - 16 km/h) over the limit
More than 10 mph (16 km/h) over the limit
21
Sub-compact or compact car
Mid-size or full-size car, or minivan
Truck, van, full-size van or SUV
Motorcycle
Other
22
5 - 6 servings a day
3 - 4 servings a day
1 - 2 servings a day
Rarely/never
23
5 - 6 servings a day
3 - 4 servings a day
1 - 2 servings a day
Rarely/never
24
Less than 1 time per week
1 or 2 times per week
3 times per week
4 or more times per week
25
None
1 day
2 days
3 or 4 days
5 or 6 days
7 days
26
Every day
Almost every day
Sometimes
Rarely or never
Does not apply
27
All of the time
Most of the time
Some of the time
Rarely or never

       QUALITY-OF-LIFE INDICATORS

28
Excellent
Very Good
Good
Fair
Poor
29
5 hours or less
6 hours
7 hours
8 hours
9 hours or more
30
Completely satisfied
Mostly satisfied
Partly satisfied
Not satisfied
31
Very strong
About average
Weaker than average
Not sure
32
Yes, two or more serious losses
Yes, one serious loss
No
33
Often
Sometimes
Rarely
Never
34
A lot
Some
Hardly any
None

       MEDICAL HISTORY AND SELF-CARE

35 Do you have:

Never
In the past
Have currently

Never
In the past
Have currently

Never
In the past
Have currently

Never
In the past
Have currently

Never
In the past
Have currently

Never
In the past
Have currently

Never
In the past
Have currently

Never
In the past
Have currently

Never
In the past
Have currently

Never
In the past
Have currently

Never
In the past
Have currently

Never
In the past
Have currently

Never
In the past
Have currently

Never
In the past
Have currently

Never
In the past
Have currently

Never
In the past
Have currently

Never
In the past
Have currently

Never
In the past
Have currently

Never
In the past
Have currently

Never
In the past
Have currently
36 When was the last time you had these preventive services or health screenings?
Less than 1 year
1 - 2 years ago
2 - 3 years ago
3 - 4 years ago
5 - 6 years ago
7 or more years ago
Never
Don't know


Less than 1 year
1 - 2 years ago
2 - 3 years ago
3 - 4 years ago
5 - 6 years ago
7 or more years ago
Never
Don't know


Less than 1 year
1 - 2 years ago
2 - 3 years ago
3 - 4 years ago
5 - 6 years ago
7 or more years ago
Never
Don't know


Less than 1 year
1 - 2 years ago
2 - 3 years ago
3 - 4 years ago
5 - 6 years ago
7 or more years ago
Never
Don't know


Less than 1 year
1 - 2 years ago
2 - 3 years ago
3 - 4 years ago
5 - 6 years ago
7 or more years ago
Never
Don't know


Less than 1 year
1 - 2 years ago
2 - 3 years ago
3 - 4 years ago
5 - 6 years ago
7 or more years ago
Never
Don't know


Less than 1 year
1 - 2 years ago
2 - 3 years ago
3 - 4 years ago
5 - 6 years ago
7 or more years ago
Never
Don't know
for Women Only
Less than 1 year
1 - 2 years ago
2 - 3 years ago
3 - 4 years ago
5 - 6 years ago
7 or more years ago
Never
Don't know


Less than 1 year
1 - 2 years ago
2 - 3 years ago
3 - 4 years ago
5 - 6 years ago
7 or more years ago
Never
Don't know


Less than 1 year
1 - 2 years ago
2 - 3 years ago
3 - 4 years ago
5 - 6 years ago
7 or more years ago
Never
Don't know
for Men Only
Less than 1 year
1 - 2 years ago
2 - 3 years ago
3 - 4 years ago
5 - 6 years ago
7 or more years ago
Never
Don't know
37 In the past 12 months, how many times have you:
0
1 - 2
3 - 5
6 or more


0
1 - 2
3 - 5
6 or more


0
1 - 2
3 - 5
6 or more

       Women (Men go to question 42)

38
Yes
No
I'm not sure
39
Younger than 12
12
13
14 or older
40
Younger than 20
20 to 24
25 to 29
30 or older
Does not apply
41
Monthly
Once every few months
Rarely or never

       Men (Women go to question 43)

42
Monthly
Once every few months
Rarely or never

       PERSONAL INFORMATION

43
Single (never married)
Separated
Divorced
Married
Widowed
Other
44
White (non-Hispanic origin)
Black (non-Hispanic origin)
Hispanic
Asian or Pacific Islander
American Indian/Alaskan Native
Other
45
Some high school or less
High school graduate
Some college
College graduate
Post graduate or professional degree
46
less than $35,000
$35,000 - $49,999
$50,000 - $74,999
$75,000 - $99,999
$100,000 or more

       HEALTH PLANNING QUESTIONS

47 In the next 6 months, are you planning to make any changes to keep yourself healthy or improve your health?
Yes
No
Don't know
Not needed


Yes
No
Don't know
Not needed


Yes
No
Don't know
Not needed


Yes
No
Don't know
Not needed


Yes
No
Don't know
Not needed


Yes
No
Don't know
Not needed


Yes
No
Don't know
Not needed


Yes
No
Don't know
Not needed
48
Yes
No
I'm not sure
49
Yes
No

       CURRENTLY EMPLOYED ONLY

50
0
1 - 2 days
3 - 5 days
6 - 10 days
11 - 15 days
16 days or more
Does not apply
51
Agree strongly
Agree
Disagree
Disagree strongly
Does not apply
52
No health problems
None of the time
Some of the time
Most of the time
All of the time
Does not apply
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.)
0
1 - 4 hours
5 - 8 hours
9 - 16 hours
17 or more hours


0
1 - 4 hours
5 - 8 hours
9 - 16 hours
17 or more hours


0
1 - 4 hours
5 - 8 hours
9 - 16 hours
17 or more hours
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
0 (Worst Performance)
1
2
3
4
5
6
7
8
9
10 (Top Performance)
59
0 (Worst Performance)
1
2
3
4
5
6
7
8
9
10 (Top Performance)
60
0 (Worst Performance)
1
2
3
4
5
6
7
8
9
10 (Top Performance)

Apr 17, 2014; 11:26:16 EDT Problems: problems@www.hmrc.kines.umich.edu