"Sample Health Risk Assessment (HRA) Form"

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Sample Health Risk Assessment (HRA)
On the answer sheet provided, please circle the number which best identifies your response to each
corresponding statement.
1. Never or Almost Never
2. Occasionally
3. Often
4. Very Often
5. Always or Almost Always
Physical Activity
8. I include foods that are high in fiber in my diet
1. I engage in moderate physical activity outside
on a daily basis (i.e. whole grain breads and
of work for at least 20 to 30 minutes at least 5
cereals, beans, etc.)
days of the week.
1
2
3
4
5
1
2
3
4
5
9. I maintain a healthy weight within the
2. My physical activity includes stretching,
recommendations specified by a health care
aerobic activity, and strength conditioning.
professional.
1
2
3
4
5
1
2
3
4
5
3. I use alternative modes of transportation
10. I avoid eating foods that are high in fat such as
whenever possible to and from various
whole milk, fried foods, fatty meats, etc.
locations (i.e. stairs instead of elevator, biking
or walking instead of driving).
1
2
3
4
5
1
2
3
4
5
General Health
4. I take the health benefits of physical activities
11. I avoid the use of tobacco products (cigarettes,
and their lasting impact seriously.
smokeless tobacco, cigars, and pipes) and limit myself
to 5 drinks of alcohol a week. (beer, liquor, wine)
1
2
3
4
5
1
2
3
4
5
5. I enjoy sedentary activities rather than physical
activities.
12. I examine my breasts or testes on a monthly basis.
1
2
3
4
5
1
2
3
4
5
Nutrition
13. I protect my skin from sun damage by using
6. I eat at least five servings of fruits and
sunscreen, wearing hats, and/or avoiding
vegetables every day (one serving equals one
tanning booths and sunlamps.
half cup).
1
2
3
4
5
1
2
3
4
5
14. I visit my dentist every six months for regular
check ups.
7. I eat at fast food restaurants less than three
times per week.
1
2
3
4
5
1
2
3
4
5
1
Sample Health Risk Assessment (HRA)
On the answer sheet provided, please circle the number which best identifies your response to each
corresponding statement.
1. Never or Almost Never
2. Occasionally
3. Often
4. Very Often
5. Always or Almost Always
Physical Activity
8. I include foods that are high in fiber in my diet
1. I engage in moderate physical activity outside
on a daily basis (i.e. whole grain breads and
of work for at least 20 to 30 minutes at least 5
cereals, beans, etc.)
days of the week.
1
2
3
4
5
1
2
3
4
5
9. I maintain a healthy weight within the
2. My physical activity includes stretching,
recommendations specified by a health care
aerobic activity, and strength conditioning.
professional.
1
2
3
4
5
1
2
3
4
5
3. I use alternative modes of transportation
10. I avoid eating foods that are high in fat such as
whenever possible to and from various
whole milk, fried foods, fatty meats, etc.
locations (i.e. stairs instead of elevator, biking
or walking instead of driving).
1
2
3
4
5
1
2
3
4
5
General Health
4. I take the health benefits of physical activities
11. I avoid the use of tobacco products (cigarettes,
and their lasting impact seriously.
smokeless tobacco, cigars, and pipes) and limit myself
to 5 drinks of alcohol a week. (beer, liquor, wine)
1
2
3
4
5
1
2
3
4
5
5. I enjoy sedentary activities rather than physical
activities.
12. I examine my breasts or testes on a monthly basis.
1
2
3
4
5
1
2
3
4
5
Nutrition
13. I protect my skin from sun damage by using
6. I eat at least five servings of fruits and
sunscreen, wearing hats, and/or avoiding
vegetables every day (one serving equals one
tanning booths and sunlamps.
half cup).
1
2
3
4
5
1
2
3
4
5
14. I visit my dentist every six months for regular
check ups.
7. I eat at fast food restaurants less than three
times per week.
1
2
3
4
5
1
2
3
4
5
1
15. I see my physician for routine check-ups,
25. I regularly take interest in and interact with
health screenings, and disease prevention.
others.
1
2
3
4
5
1
2
3
4
5
Safety
Emotional Awareness
16. I wear a seat belt when traveling in a vehicle.
26. My relationships and behaviors are maintained
in a manner which is healthy for me and for
1
2
3
4
5
others.
17. I stay within five miles per hour of the speed limit.
1
2
3
4
5
1
2
3
4
5
27. I am able to develop close, personal
relationships with others.
18. I know where to locate and properly use a first aid
kit and fire extinguisher in case of an emergency.
1
2
3
4
5
1
2
3
4
5
28. I have positive relationships with both men and
women in my life.
19. I use the recommended safety equipment for all
activities that I participate in (i.e. mouth guards,
1
2
3
4
5
life jackets, hard hats, etc.).
29. I feel that I am a confident individual.
1
2
3
4
5
1
2
3
4
5
20. I take the proper precautions to avoid or reduce
workplace accidents. (i.e. clean up spills)
30. I am able to respect others for who they are,
regardless of race, gender, age, attitude, and
interests.
1
2
3
4
5
1
2
3
4
5
Social and Environmental Wellness
21. I regularly recycle my paper, plastic, glass and
Mental Wellness
aluminum.
31. I express my feelings of anger and frustration
in ways that are not hurtful to myself or others.
1
2
3
4
5
1
2
3
4
5
22. I respect the integrity and property of my
fellow co-workers and the surrounding
32. I set reasonable objectives for myself and strive
environment.
to accomplish them.
1
2
3
4
5
1
2
3
4
5
23. I take time to have meaningful interactions
33. I realize when I make mistakes; and I
with family and friends.
understand the consequences that they have on
myself and others.
1
2
3
4
5
1
2
3
4
5
24. I contribute time and/or money to at least one
organization that strives to better the
34. I feel that I have family and friends that I can
community where I live.
confide in to assist in managing stress.
1
2
3
4
5
1
2
3
4
5
2
35. I take responsibility for my actions and
45. At work, my level of authority is consistent with my
understand the effects that they have on others.
level of responsibility.
1
2
3
4
5
1
2
3
4
5
Values, Spirituality, and Beliefs
Intellectual Wellness
46. I feel that my life has a purpose.
36. I keep informed about social, political, and/or
current events.
1
2
3
4
5
1
2
3
4
5
47. I am able to discuss my values and beliefs with my
family and friends in a reasonable manner.
37. I seek opportunities to learn new things through
different mediums such as television, books,
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2
3
4
5
newspaper, internet, etc.
48. My actions are guided by my own beliefs rather than the
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2
3
4
5
beliefs of others.
38. Before making decisions, I gather facts and
1
2
3
4
5
consider all viable options.
49. I spend a portion of every day in personal reflection.
1
2
3
4
5
1
2
3
4
5
39. I enjoy activities such as the arts, visiting
museums, or attending plays or concerts.
50. I am tolerant of the values and beliefs of others.
1
2
3
4
5
1
2
3
4
5
40. I enjoy learning new information on a daily
basis.
1
2
3
4
5
Occupational Wellness
41. I enjoy my work.
1
2
3
4
5
42. I am satisfied with the balance between my work time
and leisure time.
1
2
3
4
5
43. I am satisfied with my ability to manage and control my
work load.
1
2
3
4
5
44. The level of stress in my work environment is
manageable for me.
1
2
3
4
5
3
4
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