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Health Assessment

About You

How would you best describe your race and ethnic group?
We’d like to know about your racial and ethnic origins. The reason for this is that some diseases and
illnesses are more common in people with certain backgrounds. Please check ONE answer only

SIMPLE 7 Lifestyle Tool

Score each section based on your knowledge or perception of where you fit, if you’re not sure, a guess is OK: 2 points = Ideal; 1 point = Intermediate; 0 points = poor quality) 

STAYING ACTIVE – physical exercise and activities strengthen your body, mind and reduce your risk for cardiovascular issues. Find exercises and activities you enjoy and can engage with at least 12 times per month and consult with your primary care physician if you are just starting. How would you assess your current status regarding exercise?        
EATING HEALTHY – the quality and quantity of the nutrients you put into your body will affect how your body moves, repairs, rests and functions in the long term. Consult with a nutritionist or your primary care physician to optimize your diet and reduce your lifetime risk of cardiovascular issues. How would you assess your overall nutrition?
WATCHING YOUR BMI – rather than worrying about weight, have your Body Mass Index (BMI) calculated. The measurements of the BMI will closely approximate the body’s percentage of fat. Ideally, your BMI should below 25 in order to significantly reduce the likelihood of cardiac health issues. If your BMI is 25-29, you are at an average risk for cardiovascular disease and heart failure, and if it is 30 or higher, your risk is elevated into the highest category. Where do you know or think you fit?
BLOOD PRESSURE – your blood pressure measures your vascular health by testing how hard your heart has to work to push blood through your veins and arteries; the higher the pressure, the greater the risk of damage being caused to your heart and veins (i.e. hypertension). where do you know or think you fit?           
BLOOD CHOLESTEROL – there are 2 types of cholesterol: low-density lipoproteins (LDL) and high-density lipoproteins. Lipoproteins are made of fat on the inside and protein on the outside. These packages are essential for your body to function properly. An unhealthy amount of LDL cholesterol, however, may clog your arteries. Ideally we'd like your total cholesterol below 200. Where do you know or think you fit?
BLOOD SUGAR – knowing your blood sugar is just as important as knowing your blood pressure and cholesterol. The American Diabetes Association states the approximately 86 million American’s are currently prediabetic, a condition that your physician can identify by testing your blood sugar levels. Prediabetes can be managed with diet and exercise to prevent it from becoming full blown diabetes, a condition that raises your risk for heart disease.    Give yourself a 2 if you have a good hemoglobin A1C, a one if you're prediabetic, or 0 if you have type 2 diabetes.
TOBACCO USE – smoking damages almost every organ in your body, and the chemicals in tobacco can harm the structure and function of your blood vessels and damage your heart. If you smoke, give yourself a 0, otherwise you are 2
10-14 being optimal, 5-9 being average, and 0-4 being inadequate. Research has revealed that the overall lifetime risk for heart failure among adults aged from 45-64 is only 14.4% if they fall into the optimal category, 26.8% for average, and an alarming 48.6% for those in the inadequate category (Folsom, 2015).
Your Physical Activity

Think about a typical 7-day week. How much of the following exercise do you get?
Please write the number of days of exercise and the average time (in minutes) spent exercising.

Your Tobacco Usage
Do you smoke?
Your Drinking Habits

How many of the following non-alcoholic drinks do you usually consume in a typical day? Please write the number of each type of drink you consume in the boxes below.

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Do you drink alcohol?
Add up the total number of alcoholic drinks you consume in an average week.
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Your Eating Habits

Low-fat foods 

  • Salad, fruits and vegetables

  • Pasta and rice

  • Wholegrain breakfast cereals

  • Bread

  • Lean meat

  • Fish

  • Eggs

  • Low-fat dairy products (incl. skimmed and semi-skimmed milk)

  • Low-fat spread

High-fat foods 

  • Most carry-out and fast foods (pizza, curry, Chinese)

  • Ready meals

  • Fried foods (incl. fried breakfast)

  • Crisps and chips

  • Cakes

  • muffins and biscuits

  • Donuts

  • Pasties

  • pies and sausage rolls

  • Sausages and burgers

  • Hard cheese

  • butter and mayo

  • Regular milk and milk shakes, Chocolate bars


Low-fiber foods 

  • White bread

  • White pasta

  • rice and noodles

  • Some breakfast cereals (Corn Flakes, Rice Krispies and CoCo Pops)

  • Chips and crisps

  • Potatoes without the skin

  • Ready and microwave meals

High-fiber foods 

  • Wholegrain and brown bread

  • Brown pasta and rice

  • Nuts,

  • lentils and beans

  • Most fruits and vegetables

  • Oats

  • Wholegrain breakfast cereals (Shredded Wheat, Fruit and Fiber)

  • Jacket potatoes


Low-salt foods 

  • Fruits and vegetables

  • Grilled chicken

  • Grilled fish

  • Plain pasta

  • Unsalted nuts

  • Eggs

  • Mozzarella and most soft cheeses

High-salt foods 

  • Most ready and microwave meals

  • Cured, smoked and preserved cold meats

  • Many canned soups and foods

  • Many carry-out and fast foods (pizza, Chinese, burgers)

  • Chips and crisps

  • Corn flakes

  • Shop-bought bakery products

  • White bread

  • Ketchup

  • Creamy sauces in restaurants

How often do you eat sweet, sugary foods in a typical day?
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On a typical day how many servings of fruits and vegetables do you eat?
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Your Medical Health
Which of the following medical conditions have you been diagnosed with?
Do you regularly have any of the following bodily symptoms?

Please check all of the symptoms that apply to you.

Which of the following conditions have affected your immediate biological family (your father, mother, sisters and/or brothers)?

Please check all that apply to you. Include all conditions you know about, even if your relative is now deceased.

Your Stress
How are you coping with the stress and pressure in your life? (Please check ONE answer only.)
Here is a list of common symptoms of depression. How much has each one bothered you during the past week, including today?
How often do you find you have difficulty falling asleep or difficulty staying asleep at night?
On a regular week day when you wake up in the morning and have gotten yourself out of bed and ready for the day ahead, how rested and refreshed do you feel?
Overall, how satisfied are you with the amount and quality of the sleep that you usually get?
Your Work
Which of the following best describes your current employment status?
Your Sexual Health
Are you satisfied with your sex life?
FEMALES ONLY! Please answer the following questions. Thinking back over the past 6 months...
Your Safety
When you are driving or riding in a car, do you wear a seat belt?
Do you feel or have you ever felt unsafe or threatened in your home environment or relationships?
You said that you have at some time felt unsafe or threatened:
Have you ever been in a relationship where you have you been physically harmed or threatened with physical violence?
Are your friends or family aware of this situation?
Do you have a safe place to go and the resources you need in an emergency?
Do you feel safe in all of your current relationships?
Your Overall Health & Happiness
In general, taking all things into account, how would you rate your overall health?
In general, taking all things into account, how would you rate your satisfaction and happiness with your life?
(Please include the type if you are currently taking any of the following)
Please check everything below that describes your eating pattern and/or lifestyle behaviors
Goals & Readiness
I have fallen in the last 6 months.
Sometimes I feel unsteady when I am walking.
I am worried about falling.
I am often dizzy when I first stand up.
I have lost some feeling or have pain in my feet.
I take medicine that sometimes makes me feel light-headed or more tired than usual.
I take medicine to help me sleep or improve my mood
I often feel sad or depressed.
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Sleepiness Scale

How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you haven't done some of these things recently try to work out how they would have affected you. Place an X in the corresponding space for each situation.


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