This Health Appraisal is a voluntary offering by your employer designed to help deepen their knowledge about their employee’s health status and make important improvements where needed.
Agreement to Participate:
Completing this appraisal voluntary and there is no requirement to participate.
Information Usage:
Your employer will receive an aggregate report at the completion of the intake process that includes only high-level information (ie: 50% of participants are a healthy weight).  Your employer will not receive any personal health information or individual results.
This Health Appraisal Program prevents improper disclosure of information by complying with the HIPAA Privacy and Protected Health Information (PHI) requirements as outlined in the Medical Associates Compliance Plan.

Question Title

1. Contact Information

General Questions

Question Title

2. What is your height in feet and inches? For example, if you are 5 feet and 4 inches, write 5’4”.

Question Title

3. What is your weight? (pounds)

Question Title

4. In general, how would you rate your health?

Question Title

5. What conditions do you have, or have had in the past? (Please indicate all that apply.)

Question Title

6. Which of the following are you currently receiving treatment for? (Please indicate all that apply)

General Health

Question Title

7. I use tobacco products (cigarettes, smokeless tobacco, cigars and pipes).

Question Title

8. I limit my number of alcoholic drinks ( beer, liquor, wine) to ( per week) 5 for men and 4 for women.

Question Title

9. I visit my dentist every six months for regular check-ups.

Question Title

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

Question Title

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

Physical Activity

Question Title

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

Question Title

13. When I do physical activity it includes a variety such as stretching, aerobic activity, and strength conditioning.

Question Title

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

Question Title

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

Question Title

16. I enjoy doing physical activities rather than sedentary activities.

Nutrition

Question Title

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

Question Title

18. I include foods that are high in fiber in my diet on a daily basis (i.e. whole grain breads and cereals, beans, etc.).

Question Title

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

Question Title

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

Question Title

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

Safety

Question Title

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

Question Title

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

Question Title

24. I feel safe in my home.

Question Title

25. I am able to perform everyday activities such as eating, getting dressed, grooming, bathing, walking, or using the toilet without assistance.

Question Title

26. I take the proper precautions to avoid or reduce accidents at home.

Social and Environmental Wellness

Question Title

27. I have access to reliable transportation to get me to the places I need or want to go.

Question Title

28. Access to adequate food, clothing, utilities, and housing is a concern for me.

Question Title

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

Question Title

30. I contribute time and/or money to my community, church or other interests that I have.

Question Title

31. I get the social support I need from family and friends.

Emotional Awareness

Question Title

32. My relationship and behaviors are maintained in a manner which is healthy for me and for others.

Question Title

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

Question Title

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

Question Title

35. I feel that I am a confident individual.

Question Title

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

Mental Wellness

Question Title

37. I express my feelings of anger and frustration in ways that are not hurtful to myself or others.

Question Title

38. I feel down, depressed, or hopeless.

Question Title

39.  I rely on drugs or other medications (other than exactly as prescribed for you) to help me to relax or improve my mood.

Question Title

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

Question Title

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

Values, Spirituality, and Beliefs

Question Title

42. I feel that my life has purpose.

Question Title

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

Question Title

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

Question Title

45. I spend a portion of every day in personal reflection.

Question Title

46. I am tolerant of the values and beliefs of others.

Preventative Health

Question Title

47. Do you get a flu vaccine each year?

Question Title

48. Have you ever had one or more pneumonia shots (also called Pneumococcal vaccine)?

Question Title

49. When was the last time you had a Breast cancer screening (mammogram)?

Question Title

50. When was the last time you had a Colorectal cancer screening (colonoscopy)?

Question Title

51. When was the last time you had a Cervical cancer screening (PAP smear)?

Readiness to Change
Your Healthy Behavior
Small everyday changes can have a big impact on your health.  Think about the changes you would be most interested in making over the next year.

Question Title

52. Thinking about your health behavior, do you want to make some small lifestyle changes in this area to improve your health?  

Yes, I know the changes I want to make I want to learn more about the changes I can make I don't want to make a change right now
Clear
i We adjusted the number you entered based on the slider’s scale.

Question Title

53. How much support do you think you would get from family and friends if they knew you were trying to make some changes?

Yes, I think my family or friends would help me I think I have some support I don't think my family of friends would help me
Clear
i We adjusted the number you entered based on the slider’s scale.

Question Title

54. How much support would you like from your health care provider or health plan to make these changes?

Yes, I am interested in signing up for programs that can help me I want to learn more about programs that can help me I do not want to be contacted
Clear
i We adjusted the number you entered based on the slider’s scale.

T