"Health Risk Assessment Form - Employee and Retiree Health and Welfare Benefits Program" - Maryland

Health Risk Assessment Form - Employee and Retiree Health and Welfare Benefits Program is a legal document that was released by the Maryland Department of Budget and Management - a government authority operating within Maryland.

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Download "Health Risk Assessment Form - Employee and Retiree Health and Welfare Benefits Program" - Maryland

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State of Maryland
Employee and Retiree Health and Welfare Benefits Program
Health Assessment
Print Your Full Name:
Print Your Health Benefits Carrier Name:
Print Your Membership ID Number:
QUESTION TEXT
On scale of 1 to 10, where 0 represents the worst possible health, how would you rate
your physical health today?
Answer:
During the last month, how many days did poor health keep you from your daily
activities?
Answer:
Do you use tobacco products? (List all types. If none, write none)
Answer:
Did you eat healthy all day yesterday? Choose: yes, no, not sure
Answer:
During a typical week, do you drink alcohol? If yes, how many? (Note: One drink is
equal to one beer, one glass of wine, one mixed drink.)
Answer:
In the past week, how often did you have five or more servings of fruits and
vegetables?
Answer:
1
State of Maryland
Employee and Retiree Health and Welfare Benefits Program
Health Assessment
Print Your Full Name:
Print Your Health Benefits Carrier Name:
Print Your Membership ID Number:
QUESTION TEXT
On scale of 1 to 10, where 0 represents the worst possible health, how would you rate
your physical health today?
Answer:
During the last month, how many days did poor health keep you from your daily
activities?
Answer:
Do you use tobacco products? (List all types. If none, write none)
Answer:
Did you eat healthy all day yesterday? Choose: yes, no, not sure
Answer:
During a typical week, do you drink alcohol? If yes, how many? (Note: One drink is
equal to one beer, one glass of wine, one mixed drink.)
Answer:
In the past week, how often did you have five or more servings of fruits and
vegetables?
Answer:
1
In the past week, how often did you exercise for 30 or more minutes?
Answer:
How frequently do you use drugs or medication, including prescription drugs, to
help you relax and/or to affect your mood?
Choose: Daily, Multiple times a week, Occasionally, Never
Answer:
Has your physician prescribed any maintenance medication that you
Do not take as prescribed, or that you have not filled?
Answer:
Have you had an annual dental checkup?
Answer:
Have you ever been told by a physician or nurse that you have had any of the following:
• High Blood Pressure
Answer:
• High Cholesterol
Answer:
• Diabetes
Answer:
• Heart Attack
Answer:
• Asthma
Answer:
• Depression
Answer:
• Cancer
Answer:
2
Are you experiencing any other health problems?
Answer:
If yes, how many other health problems are you experiencing? Please enter the
number.
Answer:
Over the last month, how many days did you miss an entire day from work duties
as a result of problems with your physical or mental health? Please include only
days missed for your health, not someone else’s health.
Answer:
Over the month, how frequently did you experience little interest or pleasure in
doing things? Choose often, sometimes, rarely
Answer:
Over the past day, did you experience the following feelings most of the day?
• Sadness
Answer:
• Stress
Answer:
• Enjoyment
Answer:
• Worry
Answer:
• Physical Pain
Answer:
What is your approximate weight in lbs?
Answer:
How tall are you ? Answer:
3
What is your waist measurement in inches?
Answer:
Complete as many of the following results as you can:
• Systolic BP:
• Diastolic BP:
• Fasting glucose:
• Total cholesterol:
• HDL cholesterol:
• LDL cholesterol:
• Triglycerides:
Are there children living at home?
If yes, how many? Answer:
What is your current marital status?
Answer:
Is your health generally, excellent, very good, good, fair, or poor? Choose one.
Answer:
Do you currently see a therapist or counselor for depression? Yes or No
Answer:
Do you have a written Advance Directive? Yes or No
Answer:
4
Have you discussed your Advance Directive with your physician? Yes or No
Answer:
5
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