Fortitude Health and Wellness - a company dedicated to corporate wellness, community wellness, and personal wellness

Brooks Health System's Health Risk Assessment

Welcome to the Brooks Health System's Health Risk Assessment. We want to thank you for taking time out of your busy schedule to fill out this Health Risk Assessment. The information you provide is important and serves a dual purpose:

• To establish the overall health status of the company
• To determine which health activities and programs will most benefit you the employee

This Health Risk Assessment is a confidential document and adheres to Federal HIPPA Guidelines, which means we will not and cannot share information you provide with your employer or any other third party without your written consent. Again thank you for your participation.

Sincerely,

Janet M. Brooks
President/CEO
Fortitude Health & Wellness, Inc.

First Name:		Middle Initial:
Last Name:
Address:
City:		State:
Zip:
Home Phone:		Work Phone:
Company:
Gender:	Male	Female
Height:		Weight:
Age:
Select the answers that best pertain to you.
1. Personal Health History Has a doctor informed you that you currently have any of the following health problems?
	Heart Disease	Cancer	Diabetes	Asthma
	Stroke	High Blood Pressure	High Cholesterol	None
2. Family Health History Mark any of the following health problems found in your family (parent, brother, or sister)
	Heart Disease	Cancer	Diabetes	Asthma
	Stroke	High Blood Pressure	High Cholesterol	None
3. When was your last physical examination: Within the last

4. What is the last grade you completed?

5. What is your ethnic background?
		If other, complete:
6. How many servings of fruits and vegetables do you eat daily? (A serving is 1 cup fruit, 1/2 cup cooked, 1 medium size fruit or 3/4 cup juice)

7. How many glasses of water do you drink daily?

8. Do you take a multi-vitamin daily?
	No Yes
9. How many days per week do you participate in strength building exercises such as sit-ups, push-ups, or use weight training equipment?

10. How many days per week do you participate in aerobic exercises such of at least 20-30 minutes duration (fitness walking, cycling, jogging, swimming, aerobic dance, and active sports)

11. How many days per week do you participate in stretching exercises to improve flexibility of your back, neck, shoulder, and legs?

12. I handle changes with ease?

13. I take time for myself:

14. I have stress-related symptoms (i.e., headache, racing heart, cold hands or feet, and inability to concentrate.)

15. I have trouble sleeping

16. I feel overwhelmed by all that I have to do.

17. How well do you feel you are coping with your current stress load?

18. Do you smoke?
	Yes No
19. I drink an alcoholic beverage (one drink equals 1.5 ounces of spirits; 5 ounces of wine, or 12 ounces of beer)

20. Would you be interested in attending health related workshops?
	Yes No