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HEALTH RISK ASSESSMENT (HRA)

1.Patient Name:(Required.)
2.Date of Birth:(Required.)
3.Employer(Required.)
4.Mark all of the following that you are being treated for, taking medication for or have been diagnosed with:(Required.)
5.Number of prescribed and/or over-the-counter medications you currently take
6.In general, how would you rate your health?(Required.)
7.In general, how many days do you get at least 30 minutes of exercise each week?(Required.)
8.In general, how many servings of fruits and vegetables do you get in a typical day?(Required.)
9.Do you use tobacco products?(Required.)
10.Current/Former/ Tobacco user:
11.How many cups of coffee or caffeinated beverages do you normally consume daily?
12.How many 8 ounce glasses of water do you normally drink daily?
13.Do you consume alcohol?
14.How many drinks per week?
15.How often do you feel stress in your life?(Required.)
16.What do you consider the main source of your stress?(Required.)
17.During the past year, how often have you felt tense, anxious or depressed?
18.How many hours of sleep do you get each night?
19.Do you have any of the following symptoms?