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 Perceived health
Physical activity
Life satisfaction
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.
I don't have time to make changes.
I need help to make changes.
I have tried before and I do not think I can do it.
 4 Which of the following do you think would best help you change?
Reading printed materials about my topic chosen above.
Listening to an audio tape about my topic.
Browsing a web site on the Internet about my topic.
Speaking with a health advisor about my topic.

       Health Risks

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

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18 Do you have: Heart problems
Diabetes
Cancer
Chronic bronchitis or emphysema
Past stroke
19 When was the last time you had these preventive services or health screenings? Tetanus shot
Blood pressure
Cholesterol
Rectal exam
Colon cancer screen
Flu shot
Pneumonia shot
for Women Only Pap smear
Breast exam by physician or nurse
Mammogram
for Men Only Prostate exam
20 What is your weight? (without shoes)
21 Would you like follow-up information?
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 23, 2014; 3:01:34 EDT Problems: problems@www.hmrc.kines.umich.edu