"Health Risk Assessment Form"

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Health Risk Assessment Form
General
Nutrition
Name:
How many daily servings of
None
1 – 2
3 – 4
vegetables do you eat?
5 – 6
More
DOB:
Gender:
Height:
Weight:
How many daily servings of
None
1 – 2
3 – 4
Race:
fruit do you eat?
5 – 6
More
Medical History
How many daily servings of
None
1 – 2
3 – 4
Date of last check-up:
grains do you eat?
5 – 6
More
Allergies:
Medications:
How many daily servings of
None
1 – 2
3 – 4
Previous
meat do you eat?
5 – 6
More
Medications:
Injuries:
How many daily servings of
None
1 – 2
3 – 4
Surgeries:
sugar/carbs do you eat?
5 – 6
More
Blood Pressure:
Cholesterol:
Drug Use
How often do you smoke
Never
Occasionally
History of…
tobacco?
Often
Daily
Used to
Cancer:
Me
Relation:
How often do you chew
Never
Occasionally
Diabetes:
Me
Relation:
tobacco?
Often
Daily
Used to
Stroke:
Me
Relation:
When did the tobacco use start?
Heart Disease:
Me
Relation:
How many cigarettes do you have per day?
Heart Attack:
Me
Relation:
How many alcoholic drinks do you have per week?
Depression:
Me
Relation:
How often do you binge drink
Occasionally
Weekly
Bipolar Disorder:
Me
Relation:
(5+ drinks in 1 hour)?
Daily
Never
Have you ever been treated for alcoholism?
Females
How often do you black out/lose time?
Last date of most recent cycle:
Date of last PAP Smear:
Have you ever used recreational drugs?
Date of last breast exam:
Which drugs?
Date of last rectal exam:
Have you ever abused prescription drugs?
Year of last pregnancy:
Which drugs?
Did the pregnancy come to term?
Yes
No
Have you ever been treated for drug use?
How often do you use
Daily
Weekly
Often
Males
recreational drugs?
Occasionally
Rarely
Never
Date of last prostate exam:
Exercise
Well-Being
How many days per week do you work on cardio?
Rate your overall well-
Great
Good
Fair
Length of time spent on cardio each session:
being:
Poor
Bad
How many days per week do you work on strength?
Length of time spent on strength each session:
Great
Good
Fair
Poor
Rate your health:
Injuries/conditions that interfere with exercise:
Bad
How safe do you feel?
Very
Not Very
Not at all
Other
Volunteer Activities:
How satisfied are you
Very
Not Very
Not at all
Who do you live with?
with your life?
Do you require…?
Hearing Aid
Walker
Cane
Oxygen Tank
Glasses
How often do you feel
Always
Often
How often do you get headaches?
depressed?
Occasionally
Never
Food Sensitivities:
Current therapist:
How many hours of sleep do you get per night?
Frequency of sessions:
How restful is your
Restful
I wake up once or twice
Starting date:
sleep?
I wake up often
Fitful
www.FreePrintableMedicalForms.com
Health Risk Assessment Form
General
Nutrition
Name:
How many daily servings of
None
1 – 2
3 – 4
vegetables do you eat?
5 – 6
More
DOB:
Gender:
Height:
Weight:
How many daily servings of
None
1 – 2
3 – 4
Race:
fruit do you eat?
5 – 6
More
Medical History
How many daily servings of
None
1 – 2
3 – 4
Date of last check-up:
grains do you eat?
5 – 6
More
Allergies:
Medications:
How many daily servings of
None
1 – 2
3 – 4
Previous
meat do you eat?
5 – 6
More
Medications:
Injuries:
How many daily servings of
None
1 – 2
3 – 4
Surgeries:
sugar/carbs do you eat?
5 – 6
More
Blood Pressure:
Cholesterol:
Drug Use
How often do you smoke
Never
Occasionally
History of…
tobacco?
Often
Daily
Used to
Cancer:
Me
Relation:
How often do you chew
Never
Occasionally
Diabetes:
Me
Relation:
tobacco?
Often
Daily
Used to
Stroke:
Me
Relation:
When did the tobacco use start?
Heart Disease:
Me
Relation:
How many cigarettes do you have per day?
Heart Attack:
Me
Relation:
How many alcoholic drinks do you have per week?
Depression:
Me
Relation:
How often do you binge drink
Occasionally
Weekly
Bipolar Disorder:
Me
Relation:
(5+ drinks in 1 hour)?
Daily
Never
Have you ever been treated for alcoholism?
Females
How often do you black out/lose time?
Last date of most recent cycle:
Date of last PAP Smear:
Have you ever used recreational drugs?
Date of last breast exam:
Which drugs?
Date of last rectal exam:
Have you ever abused prescription drugs?
Year of last pregnancy:
Which drugs?
Did the pregnancy come to term?
Yes
No
Have you ever been treated for drug use?
How often do you use
Daily
Weekly
Often
Males
recreational drugs?
Occasionally
Rarely
Never
Date of last prostate exam:
Exercise
Well-Being
How many days per week do you work on cardio?
Rate your overall well-
Great
Good
Fair
Length of time spent on cardio each session:
being:
Poor
Bad
How many days per week do you work on strength?
Length of time spent on strength each session:
Great
Good
Fair
Poor
Rate your health:
Injuries/conditions that interfere with exercise:
Bad
How safe do you feel?
Very
Not Very
Not at all
Other
Volunteer Activities:
How satisfied are you
Very
Not Very
Not at all
Who do you live with?
with your life?
Do you require…?
Hearing Aid
Walker
Cane
Oxygen Tank
Glasses
How often do you feel
Always
Often
How often do you get headaches?
depressed?
Occasionally
Never
Food Sensitivities:
Current therapist:
How many hours of sleep do you get per night?
Frequency of sessions:
How restful is your
Restful
I wake up once or twice
Starting date:
sleep?
I wake up often
Fitful
www.FreePrintableMedicalForms.com