Health Assessment

Please note: If you are female and pregnant, enter your pre-pregnancy weight.

Enter the waist measurement of the most recent pair of pants that you have bought. If you don’t know your waist circumference, you can leave this blank.

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

WHITE
ASIAN OR ASIAN AMERICAN
MIXED RACE
SPANISH, HISPANIC OR LATINO
BLACK OR AFRICAN AMERICAN
OTHER ETHNIC / RACIAL GROUP
RACE & ETHNIC GROUP
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 or use chewing tobacco?
Which of the following tobacco products do you/did you use?

Please write how much tobacco you used or currently use and how long you have used it.

Screen Shot 2021-05-26 at 1.36.11 PM.png
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.

Screen Shot 2021-05-26 at 1.40.02 PM.png
Screen Shot 2021-05-26 at 1.41.35 PM.png
Screen Shot 2021-05-26 at 1.42.28 PM.png
Screen Shot 2021-05-26 at 1.43.11 PM.png
Screen Shot 2021-05-26 at 1.43.57 PM.png
Screen Shot 2021-05-26 at 1.41.10 PM.png
Screen Shot 2021-05-26 at 1.42.01 PM.png
Screen Shot 2021-05-26 at 1.42.50 PM.png
Screen Shot 2021-05-26 at 1.43.34 PM.png
Screen Shot 2021-05-26 at 1.44.20 PM.png
Do you drink alcohol?
Add up the total number of alcoholic drinks you consume in an average week.
Screen Shot 2021-05-26 at 1.49.03 PM.png
Screen Shot 2021-05-26 at 1.49.45 PM.png
Screen Shot 2021-05-26 at 1.50.18 PM.png
Screen Shot 2021-05-26 at 1.51.57 PM.png
Your Eating Habits
arrow&v

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

arrow&v

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

arrow&v

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?
Screen Shot 2021-05-26 at 2.02.41 PM.png
On a typical day how many servings of fruits and vegetables do you eat?
Screen Shot 2021-05-26 at 2.04.04 PM.png
Your Medical Health
Which of the following medical conditions have you been diagnosed with?
Which of the following preventive and screening services have you had?
Do you regularly have any of the following bodily symptoms?

Please check all of the symptoms that apply to you.

HEAD
UROGENITAL
THORAX
ABDOMEN
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
arrow&v
How are you coping with the stress and pressure in your life? (Please check ONE answer only.)
arrow&v
Here is a list of common symptoms of anxiety. How much has each one bothered you during the past week, including today?
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
Here is a list of common symptoms of depression. How much has each one bothered you during the past week, including today?
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
Have you had regular bodily pain over the last month?

Please check one answer to rate your pain in all the body areas below.

arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
Sleep
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...
arrow&v
arrow&v
arrow&v
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?
Making Changes
arrow&v
arrow&v
arrow&v
Nutrition
(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.
I use or have been advised to use a cane or walker to get around safely.
Sometimes I feel unsteady when I am walking.
I steady myself by holding onto furniture when I walk.
I am worried about falling.
I need to push with my hands to stand up from a chair
I am often dizzy when I first stand up.
I have trouble stepping up onto a curb.
I often have to rush to the toilet.
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.
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
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.

arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v

Anxiety Inventory

Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by each symptom during the PAST WEEK, INCLUDING TODAY.

arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v
arrow&v

Thanks for submitting!