Health Risk Assessment Form
Please complete this assessment to help evaluate your health risks. Your responses will remain confidential.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Other
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Lifestyle Habits
*
Rows
Never
Occasionally
Frequently
Daily
Tobacco use
1
2
3
4
Alcohol consumption
5
6
7
8
Physical activity
9
10
11
12
Sugary drinks consumption
13
14
15
16
Do you have any of the following chronic conditions? (Select all that apply)
*
Diabetes
Hypertension (High blood pressure)
Heart disease
Asthma or respiratory issues
None of the above
Other
Please rate your current stress level.
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
How many hours do you sleep on average per night?
*
Family history: Has any immediate family member been diagnosed with the following? (Select all that apply)
*
Diabetes
Hypertension
Heart disease
Cancer
Stroke
None of the above
Other
Please provide any current symptoms, health concerns, or additional information (optional)
Submit Assessment
Should be Empty: