Introduction

Thank you in advance for completing the Health Risk Assessment (HRA), which is an important part of the YCT Wellness Incentive Program. Our Wellness Program is interested in your health and wellness, and the quality of your medical care. Please select only one response per question. 

The HRA is a screening tool used to identify potential risk factors that can affect your health and quality of life.  Risk factors are things that increase or decrease the risk of developing a disease. They can be lifestyle factors such as diet and activity level, environmental factors such as air pollution, or personal characteristics such as family history, race, or age.

The HRA is not a substitute for a checkup or physical exam that you get from a doctor or nurse. However, it can give you some ideas for lowering your risk factors.   

The information you share in your HRA is private. Only the YCT Wellness Coordinator will have access to the results, and these results will be in aggregate data form only.  No names will be used.  We cannot and will not give anyone else your HRA information.  Completing your HRA does not affect where or from whom you can seek care. 

Please check the box beside the number which best identifies your response to each corresponding statement.
1. Never or Almost Never
2. Occasionally
3. Often
4. Very Often
5. Always or Almost Always

Your employer:

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* 1. Your employer:

Physical Activity
I engage in moderate physical activity outside of work for at least 20 to 30 minutes at least 5 days of the week.

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* 2. I engage in moderate physical activity outside of work for at least 20 to 30 minutes at least 5 days of the week.

My physical activity includes stretching, aerobic activity, and strength conditioning.

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* 3. My physical activity includes stretching, aerobic activity, and strength conditioning.

I use alternative modes of transportation whenever possible to and from various locations (stairs instead of elevator, biking or walking instead of driving).

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* 4. I use alternative modes of transportation whenever possible to and from various locations (stairs instead of elevator, biking or walking instead of driving).

I take the health benefits of physical activities and their lasting impact seriously.

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* 5. I take the health benefits of physical activities and their lasting impact seriously.

I enjoy sedentary activities rather than physical activities.

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* 6. I enjoy sedentary activities rather than physical activities.

Nutrition
I eat at least five servings of fruits and vegetables every day (one serving equals one half cup).

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* 7. I eat at least five servings of fruits and vegetables every day (one serving equals one half cup).

I eat at fast food restaurants less than three times per week.

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* 8. I eat at fast food restaurants less than three times per week.

I maintain a healthy weight within the recommendations specified by a health care professional.

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* 9. I maintain a healthy weight within the recommendations specified by a health care professional.

I avoid eating foods that are high in fat such as fried foods, fatty meats, etc.

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* 10. I avoid eating foods that are high in fat such as fried foods, fatty meats, etc.

General Health
I avoid the use of tobacco products (cigarettes, smokeless tobacco, cigars, and pipes) and limit myself to 5 drinks of alcohol a week. (beer, liquor, wine)

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* 11. I avoid the use of tobacco products (cigarettes, smokeless tobacco, cigars, and pipes) and limit myself to 5 drinks of alcohol a week. (beer, liquor, wine)

I examine my breasts or testes on a monthly basis.

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* 12. I examine my breasts or testes on a monthly basis.

I protect my skin from sun damage by using sunscreen, wearing hats, and/or avoiding tanning booths and sunlamps.

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* 13. I protect my skin from sun damage by using sunscreen, wearing hats, and/or avoiding tanning booths and sunlamps.

I visit my dentist every six months for regular checkups.

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* 14. I visit my dentist every six months for regular checkups.

I see my physician for routine check-ups, health screenings, and disease prevention.

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* 15. I see my physician for routine check-ups, health screenings, and disease prevention.

Safety
I wear a seat belt when traveling in a vehicle.

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* 16. I wear a seat belt when traveling in a vehicle.

I stay within five miles per hour of the speed limit.

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* 17. I stay within five miles per hour of the speed limit.

I know where to locate and properly use a first aid kit and fire extinguisher in case of an emergency.

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* 18. I know where to locate and properly use a first aid kit and fire extinguisher in case of an emergency.

I use the recommended safety equipment for all activities that I participate in (mouth guards, life jackets, hard hats).

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* 19. I use the recommended safety equipment for all activities that I participate in (mouth guards, life jackets, hard hats).

I take the proper precautions to avoid or reduce workplace accidents.

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* 20. I take the proper precautions to avoid or reduce workplace accidents.

Social and Environmental Wellness
I regularly recycle my paper, plastic, glass and aluminum.

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* 21. I regularly recycle my paper, plastic, glass and aluminum.

I respect the integrity and property of my fellow co-workers and the surrounding environment.

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* 22. I respect the integrity and property of my fellow co-workers and the surrounding environment.

I take time to have meaningful interactions with family and friends.

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* 23. I take time to have meaningful interactions with family and friends.

I contribute time and/or money to at least one organization that strives to better the community where I live.

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* 24. I contribute time and/or money to at least one organization that strives to better the community where I live.

I regularly take interest in and interact with others.

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* 25. I regularly take interest in and interact with others.

Emotional Awareness
My relationships and behaviors are maintained in a manner which is healthy for me and for others.

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* 26. My relationships and behaviors are maintained in a manner which is healthy for me and for others.

I am able to develop close, personal relationships with others.

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* 27. I am able to develop close, personal relationships with others.

I have positive relationships with both men and women in my life.

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* 28. I have positive relationships with both men and women in my life.

I feel that I am a confident individual.

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* 29. I feel that I am a confident individual.

I am able to respect others for who they are, regardless of race, gender, age, attitude, and interests.

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* 30. I am able to respect others for who they are, regardless of race, gender, age, attitude, and interests.

Mental Wellness
I set reasonable objectives for myself and strive to accomplish them.

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* 31. I set reasonable objectives for myself and strive to accomplish them.

I realize when I make mistakes and I understand the consequences that they have on myself and others.

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* 32. I realize when I make mistakes and I understand the consequences that they have on myself and others.

I feel that I have family and friends that I can confide in to assist in managing stress.

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* 33. I feel that I have family and friends that I can confide in to assist in managing stress.

I take responsibility for my actions and understand the effects that they have on others.

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* 34. I take responsibility for my actions and understand the effects that they have on others.

Intellectual Wellness
I keep informed about social, political, and/or current events.

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* 35. I keep informed about social, political, and/or current events.

I seek opportunities to learn new things through different mediums such as television, books, newspaper, internet, etc.

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* 36. I seek opportunities to learn new things through different mediums such as television, books, newspaper, internet, etc.

Before making decisions, I gather facts and consider all viable options.

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* 37. Before making decisions, I gather facts and consider all viable options.

I enjoy activities such as the arts, visiting museums, or attending plays or concerts.

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* 38. I enjoy activities such as the arts, visiting museums, or attending plays or concerts.

I enjoy learning new information on a daily basis.

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* 39. I enjoy learning new information on a daily basis.

Occupational Wellness
I enjoy my work.

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* 40. I enjoy my work.

I am satisfied with the balance between my work time and leisure time.

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* 41. I am satisfied with the balance between my work time and leisure time.

I am satisfied with my ability to manage and control my workload.

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* 42. I am satisfied with my ability to manage and control my workload.

The level of stress in my work environment is manageable for me.

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* 43. The level of stress in my work environment is manageable for me.

At work, my level of authority is consistent with my level of responsibility.

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* 44. At work, my level of authority is consistent with my level of responsibility.

Values and Beliefs
I feel that my life has a purpose.

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* 45. I feel that my life has a purpose.

I am able to discuss my values and beliefs with my family and friends in a reasonable manner.

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* 46. I am able to discuss my values and beliefs with my family and friends in a reasonable manner.

My actions are guided by my own beliefs rather than the beliefs of others.

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* 47. My actions are guided by my own beliefs rather than the beliefs of others.

I spend a portion of every day in personal reflection.

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* 48. I spend a portion of every day in personal reflection.

I am tolerant of the values and beliefs of others.

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* 49. I am tolerant of the values and beliefs of others.

To receive credit for taking part in this survey, please email Paula Tomitz with your contact information..

Paula Tomitz
YCT Wellness Coordinator
Paula.Tomitz@yc.edu

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