University of Michigan Health Management Research Center

Health Risk Appraisal Follow-up Questionnaire
HMRC Version

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 Follow-up, such as HRA Follow-up Password reminders.
Name
Address
City State Zip

Complete each question as best you can, by indicating the appropriate responses.

Your results will be kept strictly confidential.

Next Step

 1 HDL cholesterol
Safety belt use
Weight
This confidential HMRC questionnaire focuses on topics identified by the University of Michigan from your previous HMRC Health Risk Appraisal. We'll send you information about the one topic you choose.
Please choose one (1) topic

 2 For your chosen topic, which of the following statements BEST describes you? Choose one
I am not thinking about making a change in the next 6 months in my chosen topic.
I am thinking about making a change in the next 6 months.
I am making plans and getting ready to change in the next 30 days.
I have been making changes for 6 months or less.
I am maintaining a change made more than 6 months ago.
 3 Do any of the following statements keep you from making changes in your chosen topic?
I don't know how to make the changes in the topic that I have chosen.
Yes
No
I don't have time to make changes.
Yes
No
I need help to make changes.
Yes
No
I have tried before and I do not think I can do it.
Yes
No
 4 Which of the following do you think would best help you change?
Reading printed materials about my topic chosen above.
Yes
No
Listening to an audio tape about my topic.
Yes
No
Browsing a web site on the Internet about my topic.
Yes
No
Speaking with a health advisor about my topic.
Yes
No

       Health Risks

Please update the following information. Some questions may already be answered using your answers from your previous HMRC HRA.

 5
Yes
No
 6
Yes
No
 7
Yes
No
 8
Yes
No
 9
Yes
No
10
Yes
No
11
Yes
No
12
Yes
No
13
Yes
No
14
Yes
No
15
Yes
No
16
Yes
No
17
Yes
No
18 Do you have:
Yes
No
Unsure
Heart problems

Yes
No
Unsure
Diabetes

Yes
No
Unsure
Cancer

Yes
No
Unsure
Chronic bronchitis or emphysema

Yes
No
Unsure
Past stroke
19 When was the last time you had these preventive services or health screenings?
Less than 1 year
1 - 2 years ago
3 - 4 years ago
5 or more years ago
Never
Don't know
Tetanus shot

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

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

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

Less than 1 year
1 - 2 years ago
3 - 4 years ago
5 or more years ago
Never
Don't know
Colon cancer screen

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

Less than 1 year
1 - 2 years ago
3 - 4 years ago
5 or more years ago
Never
Don't know
Pneumonia shot
for Women Only
Less than 1 year
1 - 2 years ago
3 - 4 years ago
5 or more years ago
Never
Don't know
Pap smear

Less than 1 year
1 - 2 years ago
3 - 4 years ago
5 or more years ago
Never
Don't know
Breast exam by physician or nurse

Less than 1 year
1 - 2 years ago
3 - 4 years ago
5 or more years ago
Never
Don't know
Mammogram
for Men Only
Less than 1 year
1 - 2 years ago
3 - 4 years ago
5 or more years ago
Never
Don't know
Prostate exam
20 What is your weight? (without shoes)
pounds
kilograms
21 Would you like follow-up information?
Yes
No
Your phone number ( ) -

I understand that my information may be used only by approved HMRC NextStep vendors to enhance my health through personal contact or written information appropriate to my health risks.

Apr 25, 2014; 1:11:32 EDT Problems: problems@www.hmrc.kines.umich.edu