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Health Risk Assessment Questionnaire

We are performing this questionnaire to get a better understanding of your healthcare needs in order to improve our services. All responses will be confidential and only used to identify health risks and appropriate resources to offer.
1.If you are a CHP employer group member, please list your employer's name here. You must include your employer's name to receive any benefits offered by your employer for taking this questionnaire. If you are not an employer group member, please type "Individual" in this box.

Disclaimer: your personal information, excluding your first and last name, will not be shared.(Required.)
2.What is your first and last name? You must include your name to receive any benefits offered by your employer for taking this questionnaire if you are on group employer plan. 

Disclaimer: your personal information, excluding your first and last name, will not be shared.(Required.)
3.What is your email address? (Required.)
4.Is English your primary language?(Required.)
5.Do you have a vision impairment that requires special reading materials?(Required.)
6.How old are you? (Required.)
7.Which of the following do you identify as?(Required.)
8.In general, how would you rate your overall health?(Required.)
9.What is your height in feet and inches? For example, if you are 5 feet and 4 inches, write 5’4”.(Required.)
10.What is your current weight in pounds?(Required.)
11.Family Health History: Select any of the following health problems found in your family (parents, siblings).(Required.)
12.Your current health: do you have or have you been told you have any of the following health conditions?(Required.)