Web Content Viewer - Fixed Context

Web Content Viewer - Fixed Context

Health Risk Assessment

Required fields are noted with an asterisk *.

Personal Information

 
1.   In general, how do you rate your overall health?
 
2.   Do you have any of the following conditions?
Cancer
Coronary Artery Disease (CAD)
Breathing problems like Chronic
Obstructive, Pulmonary Disease (COPD)
or Asthma
Diabetes
Heart Failure
High blood pressure (HTN)
Depression
Anxiety disorder
Substance Use Disorder
Pain interfering with activity
 
3.   The next questions are about whether you need help with certain day-to-day activities
Bathing
Walking
Eating
Using the bathroom
Getting dressed
 
4.   Do you have any difficulty with the following?
Reading fine print/seeing
distance/blurry vision
Hearing
Concentrating
Remembering
Making decisions
 
5.   In the last two (2) weeks, how often have you been bothered by feeling down or having little interest or pleasure in doing things?
 
6.   Do you do any of the following?
Recreational drugs (CBD, not over-the-counter
and not prescribed)
Drink alcoholic beverages daily
Take six or more medications daily
 
7.   Do you have problems with balance or walking?
 
8.   Have you had a fall within the last six months?
 
9.   In the last six months, have you been to the emergency room or urgent care center three or more times?
 
10. In the last 12 months, have you stayed overnight as a patient one or more times in the hospital?
 
11. In the last 12 months, have you had difficulty with the following?
Food
Living situation
Utilities
Transportation to your
appointments
Financial strain
Medication costs
 
12. Do you live in a shelter or are you currently homeless?
 
13. How often does anyone, including family and friends, physically hurt you?
 
14. Do you feel safe in your home?
 
15. Do you have a Primary Care Physician (PCP)?
 
16. Are you up to date with your preventive screenings?
Mammography
Colonoscopy
Vision exam
Hearing exam
Dental exam
 
17. Do you have someone to assist with healthcare decisions (for example if you were no longer able to talk)?
 
18. Which of the following best describes your race or ethic group?
 
19. If we have questions regarding any information in the HRA document, please select which method(s) we can use to contact you.

Consent

With your permission, we would like to share your health risk assessment with your provider of choice.

Web Content Viewer - Fixed Context

Updated October 1, 2022

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