Ontario County Health Risk Assessment (HRA) Yr 2

Healthy Living Partnership

What is the HRA? HRA stands for Health Risk Assessment. The HRA survey tool consists of ten simple questions related to individual lifestyle practices that have the highest impact on individual health. Lifestyle questions focus on exercise, nutrition, smoking, alcohol, stress,and well-being.

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* What is your zip code? Please click on drop down arrow.

If your zip code is not listed please enter it here.

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* Is this the first time or second time you've completed a Health Risk Assessment?

First

Second

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* Please provide us with a four digit code. Such as the last 4 digits of your S.S.#, last 4 of your phone number, any other 4 digit # that you will remember. Please use last year's number if you remember it.

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* Please choose the closest site to your normal workplace?

Canandaigua

Geneva

Hopewell

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* 1. Current physical activity level.

Select the statement that best describes your current level of physical activity.
Vigorous exercise includes: jogging, running, fast cycling, aerobic classes, swimming laps, singles tennis and racquetball.
Moderate exercise includes: brisk walking, gardening, slow cycling, dancing, doubles tennis or hard work around the house.

I don't exercise or walk regularly now, and I don't plan to start in the near future.

I don't exercise or walk regularly, but I've been thinking about starting.

I'm doing moderate or vigorous physical activities for at least 30 minutes on some days, but fewer than 5 days a week.

I've been doing moderate or vigorous physical activities for at least 30 minutes in a day, on five or more days a week, and have been doing it for the last 1 to 6 months.

I've been doing moderate or vigorous physical activities for at least 30 minutes in a day, on five or more days a week, and have been doing it for 7 months or longer.

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* 2. When do you get most of your physical activity each day?

Before work

During work hours on break and lunch times

After work

None of the above. I am not physically active or am only active on weekends.

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* 3. Fruits and Vegetables.

What is your current intake of 100% juices and fresh, frozen and/or dried fruits and vegetables? A serving is ½ cup or 1 medium piece of most fresh or frozen fruits and vegetables, 6 ounces of 100% juice and/or ¼ cup of dried fruits or vegetables.

I don't eat fruits and vegetables regularly and don't plan to start in the near future.

I don't eat fruits and vegetables regularly, but I've been thinking about starting.

I'm eating some fruits and vegetables a day (total of 2 servings or less)

I've been eating fruits and vegetables every day (total of 3 or more servings), for the last 0 to 6 months.

I've been eating 5 or more servings of fruits and vegetables every day, for more than 6 months.

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* 4. Fat in Foods

What is your current intake of low fat foods?

I don't worry about fat content and don't plan to in the near future.

I eat high fat foods daily, but I've been thinking about trying to reduce my intake.

I limit my intake of high fat foods to 1-3 times/week.

I eat high fat foods less than once/week and have been for the past 6 months.

I eat high fat foods less than once/week and have been for more than 6 months.

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* 5. Whole grains

What is your current intake of whole grain foods? The serving size for whole grains is one ounce (example: 1 slice of bread, 1 oz. of cereal, ½ cup of cooked rice or pasta).

I don't cook, eat or purchase whole grain foods and don't plan to start in the near future.

I don't cook, eat or purchase whole grain foods regularly, but I've been thinking about starting.

I'm cooking, eating or purchasing whole grain foods 3-4 times a week.

I've been cooking, eating or purchasing whole grain foods every day, for the past 1 to 6 months.

I've been cooking, eating or purchasing at least 3 servings of whole grain foods every day, for 7 months or longer.

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* 6. Tobacco/Smokeless Tobacco Use What is your current tobacco/smokeless tobacco use? For free information on quitting smoking click here.

I don’t smoke cigarettes or use smokeless tobacco products

I’m not thinking about quitting, at least not in the next six months

I’m thinking about quitting someday, but not right now

I want to quit within the next month or two, and I want to know more about how to do it

I have just quit and I am going through withdrawal.

I have quit smoking (stopped using smokeless tobacco products) and I want to know more about how to never smoke again

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* 7. Anxiety

About how often during the past 30 days did you feel nervous or anxious?

All

Most

Some

A little

None

Don’t know/not sure

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* 7. Depression

About how often during the past 30 days did you feel sad, blue or depressed?

All

Most

Some

A little

None

Don’t know/not sure

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* 9. Since participating in worksite wellness…

	Yes	No
I have increased my physical activity level	I have increased my physical activity level Yes	I have increased my physical activity level No
I consume more fruits and vegetables	I consume more fruits and vegetables Yes	I consume more fruits and vegetables No
I have increased my intake of low fat foods	I have increased my intake of low fat foods Yes	I have increased my intake of low fat foods No
I have increased my intake of whole grain foods	I have increased my intake of whole grain foods Yes	I have increased my intake of whole grain foods No
I have cut down on my tobacco use	I have cut down on my tobacco use Yes	I have cut down on my tobacco use No
I have quit my tobacco use	I have quit my tobacco use Yes	I have quit my tobacco use No
I am more aware of my anxiety level and have been made aware of ways to cope	I am more aware of my anxiety level and have been made aware of ways to cope Yes	I am more aware of my anxiety level and have been made aware of ways to cope No
I am more aware of my moods and have been made aware of ways to cope	I am more aware of my moods and have been made aware of ways to cope Yes	I am more aware of my moods and have been made aware of ways to cope No

Ontario County Health Risk Assessment (HRA) Yr 2

Healthy Living Partnership

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* What is your zip code? Please click on drop down arrow.

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* Is this the first time or second time you've completed a Health Risk Assessment?

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* Please provide us with a four digit code. Such as the last 4 digits of your S.S.#, last 4 of your phone number, any other 4 digit # that you will remember. Please use last year's number if you remember it.

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* Please choose the closest site to your normal workplace?

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* 2. When do you get most of your physical activity each day?

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* 3. Fruits and Vegetables.

What is your current intake of 100% juices and fresh, frozen and/or dried fruits and vegetables? A serving is ½ cup or 1 medium piece of most fresh or frozen fruits and vegetables, 6 ounces of 100% juice and/or ¼ cup of dried fruits or vegetables.

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* 4. Fat in Foods

What is your current intake of low fat foods?

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* 5. Whole grains

What is your current intake of whole grain foods? The serving size for whole grains is one ounce (example: 1 slice of bread, 1 oz. of cereal, ½ cup of cooked rice or pasta).

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* 6. Tobacco/Smokeless Tobacco Use What is your current tobacco/smokeless tobacco use? For free information on quitting smoking click here.

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* 7. Anxiety

About how often during the past 30 days did you feel nervous or anxious?

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* 7. Depression

About how often during the past 30 days did you feel sad, blue or depressed?

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* 9. Since participating in worksite wellness…

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* 10. Please share with us your success story, have you lost weight?, gotten your blood pressure under control?, lowered your cholesterol?, etc.

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* Do you have any suggestions for your worksite wellness program?

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* What is your zip code? Please click on drop down arrow.

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* Is this the first time or second time you've completed a Health Risk Assessment?

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* Please provide us with a four digit code. Such as the last 4 digits of your S.S.#, last 4 of your phone number, any other 4 digit # that you will remember. Please use last year's number if you remember it.

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* Please choose the closest site to your normal workplace?

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* 2. When do you get most of your physical activity each day?

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* 3. Fruits and Vegetables.What is your current intake of 100% juices and fresh, frozen and/or dried fruits and vegetables? A serving is ½ cup or 1 medium piece of most fresh or frozen fruits and vegetables, 6 ounces of 100% juice and/or ¼ cup of dried fruits or vegetables.

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* 4. Fat in FoodsWhat is your current intake of low fat foods?

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* 5. Whole grainsWhat is your current intake of whole grain foods? The serving size for whole grains is one ounce (example: 1 slice of bread, 1 oz. of cereal, ½ cup of cooked rice or pasta).

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* 6. Tobacco/Smokeless Tobacco Use What is your current tobacco/smokeless tobacco use? For free information on quitting smoking click here.

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* 7. AnxietyAbout how often during the past 30 days did you feel nervous or anxious?

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* 7. Depression About how often during the past 30 days did you feel sad, blue or depressed?

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* 9. Since participating in worksite wellness…

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* 10. Please share with us your success story, have you lost weight?, gotten your blood pressure under control?, lowered your cholesterol?, etc.

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* Do you have any suggestions for your worksite wellness program?

* 3. Fruits and Vegetables.

What is your current intake of 100% juices and fresh, frozen and/or dried fruits and vegetables? A serving is ½ cup or 1 medium piece of most fresh or frozen fruits and vegetables, 6 ounces of 100% juice and/or ¼ cup of dried fruits or vegetables.

* 4. Fat in Foods

What is your current intake of low fat foods?

* 5. Whole grains

What is your current intake of whole grain foods? The serving size for whole grains is one ounce (example: 1 slice of bread, 1 oz. of cereal, ½ cup of cooked rice or pasta).

* 7. Anxiety

About how often during the past 30 days did you feel nervous or anxious?

* 7. Depression

About how often during the past 30 days did you feel sad, blue or depressed?