University of Michigan Health Management Research Center

 

Health Risk Assessment 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 Assessment, 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.

 

QUESTIONS
1-10
Your Information
 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)
 
Start

QUESTIONS
11-27
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
 
17%
complete

QUESTIONS
28-34
Quality-of-Life Indicators
28
 
29
 
30
 
31
 
32
 
33
 
34
 
45%
complete

QUESTIONS
35-37
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:

 
57%
complete

QUESTIONS
38-41
Women (Men go to question 42)
38
 
39
 
40
 
41
 

QUESTION
42
Men (Women go to question 43)
42
 
62%
complete

QUESTIONS
43-46
Personal Information
43
 
44
 
45
 
46
 
70%
complete

QUESTIONS
47-49
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
 
77%
complete

QUESTIONS
50-60
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
 
83%
complete

Apr 18, 2015; 21:02:37 EDT Problems: problems@www.hmrc.kines.umich.edu