Health Risk Appraisal Questionnaire


Health risk appraisal questionnaire is a document which is used by varied medical entities to carry on the health risk assessment of the individuals i.e. patients. Health risk assessment is process via which a medical examiner or doctor accesses the health risk to a certain individual’s health and the quality of life he or she has.

By analyzing the answers to the questionnaire a risk score is calculated; based on this risk score or risk calculation the individual is given a feedback i.e. suggestions to improve the quality of life.

Sample Health Risk Appraisal Questionnaire

Name:

Gender:

Blood group:

Contact No.:

Address:

Kindly provide the answers to the following questions appropriately:

1. Mention the following details, give exact recent figures:

a. Height – ________ feet ________ inches

b. Weight- ________ pounds

c. Age- ____________ years

2. Have you been diagnosed with diabetes by your doctor? If yes then mention how long ago and the current sugar level.

______________________________________________________________________

3. Do you have any blood pressure related problems i.e. high or low? If yes then mention since how long and the name of the medication if you are taking any currently.

______________________________________________________________________

4. Does your family have any history of any heart diseases? Have any of your family members been diagnosed with heart disease? Give specifications.

______________________________________________________________________

5. Mention your Total cholesterol level along with your HDL cholesterol level? (both based on blood test results)

______________________________________________________________________

6. Do you smoke or have ever smoked? If yes then specify cigarettes or cigars, the amount and frequency of your smoking habit.

______________________________________________________________________

7. Do you exercise? If yes then how often and type of exercise (walk, gym, cardio etc)

______________________________________________________________________

8. Do you consume or have ever consumed alcohol? Specify

______________________________________________________________________

9. Mention your work type and working hours.

______________________________________________________________________

10. Describe your eating habits and your daily diet.

______________________________________________________________________

11. Describe your daily routine including sleeping time, wake up time etc.

______________________________________________________________________

Category: Health Questionnaire

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