Health Risk Assessment
General Health Risk Assessment
If you are uncertain as to your employer’s participation in HealthComp’s Wellness Program, please contact your Human Resource Department or HealthComp at 800-755-7247
Required fields are marked with *
Demographics
First Name *  Last Name * 
Address Line 1 * 
Address Line 2
City * 
State *  Zip *  
Member ID *  Gender *   
Age *  DOB * (mm/dd/yyyy)
Height * Feet Inches Weight * Pounds  
Ethnicity Body Frame *  
Occupation Work Location
Phone * Email
Personal Health Habits
When was the date of your last physical exam? *
Date   Calendar  
Are you involved in a regular exercise program? *
 
How many times per week do you exercise? *
 
What is the intensity of your exercise on average? *
 
Do you use tobacco? Include pipes and cigars. *
 
How often used?


If you smoke how many per day?


For how long have you smoked/chewed?
Years
If you smoke/chew, would you like to quit?


Do you drink alcohol, what type do you drink? *
 
How often do you drink? *
 
Personal Health Risk
In general, how would you rate your health, compared to other people your age? *
 
Compared to one year ago, how would you rate your health today? *
 
How many prescription medications are you currently taking? *
 
What is your blood pressure?
/ (exmaple: 120/80)
If you do not remember your blood pressure values, how would you describe your blood pressure?


What is your total cholesterol level?
If you do not know your total cholesterol level, how would you describe it?


Have you been diagnosed with chronic lung disease? *
 
If yes, what type (asthma, COPD, emphysema, etc.)?
How often do you use your rescue inhaler per week?


Have you ever been to the ER for asthma? When?


If Yes, Date   Calendar
How long has it been since you've seen your doctor? *
 
Dietary/Nutritional Risks
Do you eat breakfast at least five times per week? *
 
Do you eat some foods every day that are high in fiber? (Such as whole grains, cereal, fresh fruit or vegetables). *
 
Do you eat some foods every day that are high in cholesterol? (Such as fatty meats, cheese, fried foods, butter or whole milk). *
 
Do you drink eight glasses (8 ounces) of water daily? *
 
Safety Risks
On a typical day, what mode of transportation do you use? *
 
How often do you buckle your seatbelt when you are in an automobile? *
 
On the average, how close to the speed limit do you drive? *
 
If you ride a bicycle, motorcycle, or ATV, how often do you wear a helmet? *
 
Do you ever operate a vehicle or ride with someone who is under the influence of a drug or alcohol? *
 
Mental Health Risk
Do you get the right amount of sleep for your needs and feel rested when you get up? *
 
Do you find pleasure in the things that you do? *
 
In general, do you feel satisfied with your accomplishments? *
 
Do you have the energy to take on the day's demands? *
 
Do you focus on tasks at hand to accomplish them? *
 
Are you within 10 pounds of your ideal body weight? *
 
Do you feel in control of situations in your life? *
 
Do you have trouble recalling recent events in life or sometimes forgetful? *
 
Have you suffered misfortune or personal loss in the past 12 months that has had a serious impact on your life? *
 
Have you experienced a major life event in the last year (such as a marriage, childbirth, home purchase, new job)? *
 
Do you have to work harder than your peers for the same results? *
 
Do you have trouble gaining and maintaining good relationships with others (either friendship or intimate relationships)? *
 
 

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