University of Michigan / Health Management Research Center

Healthy Life Assessment

Healthy Life Assessment

The assessment below is only a sample for demonstration purposes.

Email
If possible, please provide an email address. It is used only for infrequent communication regarding this Healthy Life Assessment, such as HLA Password reminders.
Name
Address
City State Zip
 

Please complete each question as best you can, by indicating the best response. This Healthy Life Assessment is not designed for people who already have heart disease, cancer, kidney disease, or other serious conditions.

 

Your results will be kept strictly confidential.

 

A Positive and Healthy Life is much more than thinking about disease. Your health impacts those around you including your family, your friends, your co-workers, your company or organization and your community. In this survey we will ask you about your daily living activities, your risks for disease and other questions about how they impact you and your family. All of the sections include important considerations for your overall health, well-being, performance and general happiness and satisfaction with life.

 

QUESTIONS
1-6
DEMOGRAPHICS
 1 Identification Number Confirmed
 
 2 Home Zip Code
 
 3 Gender
 
 4 Age (at last birthday)
 
 5
Single
Married
Separated
Divorced
Widowed
Other
 
 6
Yes
No
Does not apply
If Yes, complete assessment based on your health condition and lifestyle before pregnancy.
 

Apr 24, 2014; 0:28:58 EDT © Copyright 2014 University of Michigan Health Management Research Center Problems: problems@www.hmrc.kines.umich.edu