Health Risk Assessment - Adult

Member first name:

Member last name:

Date of Birth (DD/MM/YYYY):

Email Address:

Phone number:

Mailing Address:

What is your Medicaid ID Number?

What is your preferred spoken language?

What is your preferred written language?

What is your ethnicity?

What is your gender: Male Female

What is your weight?

What is your height?

Do you have a person you think of as your personal doctor or health care provider? Yes No

If you answered "Yes" in the previous question, what is their name?

If you answered "Yes" in the previous question, what is their phone number?

How do you prefer to get health and wellness information?

Would you say that in general your health is?

If aged 50 years or older:
A blood stool test is a test that may use a special kit at home to determine whether the stool contains blood. When did you last have this test using a home kit?

Colonoscopy is an exam in which a tube is inserted in the rectum to view the colon for signs of cancer or other health problems. You are usually given medication through a needle in your arm to make you sleepy and told to have someone else drive you home after the test. When was the last time you had a colonoscopy?

Women only: If aged 40 – 49 years, when did you have your last mammogram?

Women only: If aged 50 years, when did you have your last mammogram?

Women only: If 21 – 64 years years, when did you have your last Pap smear?

If currently using any tobacco products: How many times have you tried to quit in the past?

How often are you exposed to second-hand smoke at home or at work? Seldom or never
Occasionally
Daily

Male section: How often do you have a drink containing alcohol?

How many drinks containing alcohol do you have on a typical day when you are drinking?

How often do you have 5 or more drinks on one occasion?

Female section: How often do you have a drink containing alcohol?

How many drinks containing alcohol do you have on a typical day when you are drinking?

How often do you have 5 or more drinks on one occasion?

Diet and Exercise:

About how much do you weigh without shoes?

About how much do you weigh without shoes?

How would you describe your eating habits? According to Dietary Guidelines for Americans a healthy well-balanced diet is mostly vegetables, fruit, whole grains, low-fat milk products, and lean proteins such as fish, chicken, and beans. And it is low in salt, solid fats, and added sugar.

What are the reasons that make it difficult to maintain well-balanced eating habits? Mark all that apply

Besides at work, how often are you able to engage in physical activity (like brisk walking, cycling, or sports)? Rarely
Few times per week
Most days
I have physical activity
scheduled into my daily routine.

Are you interested in increasing your physical activity? Yes No

What are the reasons you don't get more physical activity?

Have you been sexually active over the last year? Yes No (skip to end)

Do you use protection to decrease the risk of sexually transmitted diseases when you have sex? Yes, all the time
Sometimes
No, never
No, I only have
one sexual partner

Would you like to have a baby in the next year? Yes
No
I'm unsure or OK either way

If no: What type of birth control (contraception) are you currently using? Mark all that apply