Health Risk Assessment Questionnaire
Your Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Would you consider yourself as healthy?
Yes, I'm a healthy person
No, I don't feel like a healthy person
I'm not sure
How happy are you with your life?
I'm very happy with my life, have no problems at all
I'm neither happy nor unhappy with my life
I'm unhappy with my life
I can't decide
How often do you do physical activities/exercises?
Every day
Couple of times a week
Once or twice a month
Never
Do you use seat belts?
Always
Sometimes
Never
Do you sleep well?
Always
Usually
Sometimes
Never
Do you eat a healthy diet?
Yes, in general
Sometimes
Not at all
Do you smoke cigarettes?
Yes
I used to smoke
Never
How much alcohol do you consume?
Every day
2-3 times a week
Once or twice a month
Never
Do you have any of the following chronic diseases?
Asthma
Cancer
Diabetes
Other
Do you have any infectious diseases or sexually transmitted diseases?
Yes
No
Do you have any disabilities?
Yes
No
Does your family have any medical history?
Yes
No
Don't know
Do you have any of the following mental/emotional health conditions?
Stress
Depression
Anxiety
Other
Please verify that you are human.
*
Submit
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