Sample Work Well Health Assessment

Helping Policy Makers Discover the Health and Productivity Connection – understanding the personal relevance of wellness in their own lives.

Start with a privacy statement and informed consent. Describe how the information will be used, anonymity and confidentiality, not necessary or required to answer any or all questions. Describe how the individual will get a personalized report with personal results and tailored recommendations.

1. What is your age in years?______2. What is your sex?Female Male

Questions for Women Only (men please go to question 9. on next page)

3. A mammogram is an x-ray taken only of the breasts by a machine that presses the breast against a plate. Have you ever had a mammogram and if so when?

  • Never
  • Was it a year ago or less
  • More than 1 year but not more than two years ago
  • More than two years but not more than three years ago
  • More than three years but not more than five years ago
  • Over 5 years ago
  1. Have you ever had a pap smear test?
  • Never
  • Was it a year ago or less
  • More than 1 year but not more than two years ago
  • More than two years but not more than three years ago
  • More than three years but not more than five years ago
  • Over 5 years ago

5. Have you had your breasts examined by a health professional within the last year?

YesNo

6. Do you do a breast self-exam every month or most months?

YesNo

7. Are you pregnant or do you plan to become pregnant in the next 6-months?

YesNo

8. Have you followed your doctor's advice about having an exam to detect colon cancer, such as a test for blood in the stool, sigmoidoscopy or colonscopy?

I have not been given this adviceYesNo

Questions for Men Only

9. Have you had a rectal exam in the past year?YesNo

10. Have you had a blood test for PSA (prostate specific antigen) in the past year?

YesNo

11. Have you followed your doctor's advice about having an exam to detect colon cancer, such as a test for blood in the stool, sigmoidoscopy or colonscopy?

I have not been given this adviceYesNo

12. How tall are you in inches?______13. What is your weight in pounds?______

14. Considering your age, how would you describe your general health?

Excellent / Very good / Good / Fair / Poor / Don't know

15. Have you smoked at least 100 cigarettes in your entire life?

YesNo

If you answer "Yes" go question 17 and if "No" please answer the next two questions

Questions for having smoked at least 100 cigarettes

16. Do you now smoke cigarettes everyday, some days, or not at all?

If you answer "Everyday" or "Some days" go to question 17.

If you answer "Not at all" you will be taken to question 18.

Everyday / Some days / Not at all

17. During the past 12 months, have you stopped smoking for 1 day or longer BECAUSE YOU WERE TRYING TO QUIT SMOKING?

YesNo

18. During the past 30 days, on how many days did you have 5 or more alcoholic drinks if you are a male (or 4 or more drinks if you are female) on the same occasion?
By “occasion,” we mean at the same time or within a couple of hours of each other.

Males: days had 5 or more drinks

Females: days had 4 or more drinks

YesNo

19. If you never had 5 or more drinks if you are a male (4 or more for females) on the same occasion on any day when you drank during the past 30 days check the appropriate box below.

  • Have drunk alcoholic beverages, but not during the past 30 days
  • Never drunk an alcoholic beverage in your life

20. How often do you do VIGOROUS activities for AT LEAST 10 MINUTES that cause HEAVY sweating or LARGE increases in breathing or heart rate?
And about how many minutes each time.

Times per week______

Minutes each time______

21. How often do you do LIGHT OR MODERATE activities for AT LEAST 10 MINUTES that cause ONLY LIGHT sweating or a SLIGHT TO MODERATE increase in breathing or heart rate?
And about how many minutes each time?

Times per week______

Minutes each time______

22. How often per week do you do physical activities specifically designed to STRENGTHEN your muscles such as lifting weights or doing calisthenics? (Include all such activities even if you have mentioned them before.)

Times per week______

23. How often in the past 2 weeks have you done stretching exercises?

Times in past 2 weeks______

24. How many servings of fruits do you usually have per day? A serving is:

 1 medium piece of fruit (example: apple or orange size of a tennis ball);

 1/2 measuring cup of chopped or cooked, fresh, frozen or canned fruits (a small handful);

 3/4 measuring cup of 100% fruit juice

 lunch-box size container of unsweetened applesauce or

 1/2 measuring cup of dried fruit.

A measuring cup is also about the same size as a medium size piece of fruit.

0 servings / 1 servings / 2 servings / 3 servings / 4 servings / 5 or more

25. How many servings of vegetables do you usually have per day? A serving is:

 1/2 measuring cup of chopped or cooked, fresh, frozen or canned vegetables;

 1/2 cup cooked, canned or frozen legumes (beans and peas);

 3/4 measuring cup of 100% vegetable juice;

 1 cup raw, leafy vegetables, 4 leaves: or

 5-6 baby carrots.

0 servings / 1 servings / 2 servings / 3 servings / 4 servings / 5 or more

26. On how many of the past 7 days did you get enough sleep so that you felt rested when you woke up in the morning?

0 / 1 / 2 / 3 / 4 / 5 / 6 / 7

27. Within the last 12 months, how many times have you felt so depressed that it was difficult to function?

Never / 1 - 2 times / 3 - 4 times / 5 - 6 times / 7 - 8 times / 9 - 10 times / 11 or more times

28. Within the last 12 months, did relationship difficulties affect your work performance or off-work quality of life? Please select the most serious outcome.

  • This did not happen to me / not applicable
  • Experienced relationship difficulties, but my work or off-work quality of life were not affected
  • Had poor performance on an important short-term (less than a few weeks) project at work or away from work
  • Had poor performance at work or away from work over a 3-month period
  • Had to quit working on a major project at work or away from work

29. Within the last 12 months, did stress affect your work performance or off-work quality of life? Please select the most serious outcome.

  • This did not happen to me / not applicable
  • Experienced relationship difficulties, but my work or off-work quality of life were not affected
  • Had poor performance on an important short-term (less than a few weeks) project at work or away from work
  • Had poor performance at work or away from work over a 3-month period
  • Had to quit working on a major project at work or away from work

30. Within the last 12 months, did sleep difficulties affect your work performance or off-work quality of life? Please select the most serious outcome.

  • This did not happen to me / not applicable
  • Experienced relationship difficulties, but my work or off-work quality of life were not affected
  • Had poor performance on an important short-term (less than a few weeks) project at work or away from work
  • Had poor performance at work or away from work over a 3-month period
  • Had to quit working on a major project at work or away from work

31. Within the last 12 months, did concern for a troubled family member or friend affect your work performance or off-work quality of life? Please select the most serious outcome.

  • This did not happen to me / not applicable
  • Experienced relationship difficulties, but my work or off-work quality of life were not affected
  • Had poor performance on an important short-term (less than a few weeks) project at work or away from work
  • Had poor performance at work or away from work over a 3-month period
  • Had to quit working on a major project at work or away from work

32. Within the last 12 months, did an injury affect your work performance or off-work quality of life? Please select the most serious outcome.

  • This did not happen to me / not applicable
  • Experienced relationship difficulties, but my work or off-work quality of life were not affected
  • Had poor performance on an important short-term (less than a few weeks) project at work or away from work
  • Had poor performance at work or away from work over a 3-month period
  • Had to quit working on a major project at work or away from work

33. Within the last 12 months, did colds/flu/core throats affect your work performance or off-work quality of life? Please select the most serious outcome.

  • This did not happen to me / not applicable
  • Experienced relationship difficulties, but my work or off-work quality of life were not affected
  • Had poor performance on an important short-term (less than a few weeks) project at work or away from work
  • Had poor performance at work or away from work over a 3-month period
  • Had to quit working on a major project at work or away from work

34. Do you have any kind of health insurance (including prepaid plans such as HMOs - health maintenance organizations)?

Yes / No / Don't know

Have you had your blood pressure checked in the past two years?

Yes / No / Don't know

35. When was the last time that you had your blood cholesterol level checked by a doctor or health professional?

  • Never
  • A year ago or less
  • More than 1 year but not more than 2 years
  • More than 2 years but not more than 3 years
  • More than 3 years but not more than 5 years
  • Over 5 years

36. What is your relationship status?

  • Single
  • Married or have a domestic partner
  • Engaged or in a committed dating relationship
  • Separated
  • Divorced
  • Widowed

37. How do you usually describe yourself? Mark all that apply.

  • American Indian or Alaskan Native
  • Asian or Pacific Islander
  • Black
  • Hispanic or Latino
  • White
  • Other (please specify)

38. This is very important: Type one or two things you are serious about doing in the next 6-months to improve your health.

1st______

2nd______

39. What might be the reason or reasons you would like to do the one or two things you listed in question 38?

______

Online version of questionnaire is at:

1

Jim Grizzell, MBA, MA, CHES – – 909-856-3350