Annual Health Risk Assessment
Assessment Type: Annual / Date of Assessment:1 / In the past 6 months, have you missed any medical appointments because of problems with transportation? /
- Yes
- No
2 / In the past 6 months, have you had problems paying for food for you and your family? /
- Yes
- No
3 / In the past 6 months, have you had problems paying for medicines prescribed by your doctor? /
- Yes
- No
4 / Are you taking your medications as prescribed by your doctor? /
- Yes
- No
- Not sure
5 / Are you taking 6 or more prescribed medications? /
- Yes
- No
6 / Are you following the treatment plan recommended by your doctor? (i.e. taking medications correctly, making diet or exercise changes, etc.) /
- Yes
- No
7 / Considering your age, how would you rate your overall health? /
- Poor
- Average
- Good
8 / Has a doctor or other health care provider ever told you that you have any of the following conditions? If yes, which ones? /
- Cancer
- Kidney Disease
- Mental Health Condition (Bipolar, Schizophrenia)
- Depression
- Diabetes
- Heart Disease (Coronary Artery Disease, Congestive Heart Failure, Atrial Fibrillation)
- Hypertension(High Blood Pressure)
- Liver Disease (Hepatitis, Cirrhosis)
- Lung Disease (Asthma, COPD, Emphysema)
- Stroke
- None of These
9 / In the past 12 months, how many times have you been admitted to the hospital? /
- None
- 1 time
- 2 or more times
10 / In the past 6 months, how many times have you gone to the emergency room for care? /
- None
- 1 or 2 times
- 3 or more times
11 / Over the past 2 weeks, how often have you had little pleasure or interest in doing things? /
- Not at all
- Several days
- More than half the days
- Nearly every day
12 / Over the past 2 weeks, how often have you felt down, depressed or hopeless? /
- Not at all
- Several days
- More than half the days
- Nearly every day
For Staff Use Only
13 / Blood Pressure at current visit: /
- <120/<80
- 120-139/80-89
- 140-159/90-99
- >160/>100
14 / BMI: /
- 18-24
- 25-29
- ≥30
15 / Age: /
- 18-44
- 45-64
- 65+
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