Health Risk Assessment Questionnaire


The health risk assessment questionnaire is prepared by physicians and health care professionals to assess the health condition of the patient. The health risk assessment questionnaire addresses topics such as blood results, lung capacity, all major lifestyle factors, personal and family history, symptoms, functional health status and quality of life, health interests, readiness for change, self-efficacy, overall wellness, current fitness level, heart health, stress and coping, eating habits, drug and alcohol use, and medical care.

It helps in helping patients make healthy lifestyle decisions and make appropriate use of medical services and to provide an organized approach to review a patient or organization’s use of medical services.

Health Risk Assessment Questionnaire Sample

 

Name:

Age:

Weight:

Sex:

  1. If you had to rate your health between1 to 5, how would you rate it?
  1. Do you currently smoke cigarettes, pipe, cigar or hookah?
  1. How often do you consume alcohol?
  1. How many alcoholic beverages do you take during a day when you drink?
  1. How often do you feel that your work pressure is putting you under stress?
  1. Do you usually feel depressed, angry or in need of help?
  1. How often do you have sex?
  1. How often do you use protection whenever you have sex?
  1. How often do you exercise?
  2. How often do you eat high-fat food?
  1. How often do you have fruits or leafy vegetables?
  1. Do you have your regular meals on time?
  1. How many hours of sleep do you take?
  1. Do you use any dietary products or herbal products to manage your weight?
  1. Do you feel that you get enough sleep to manage your daily life?

Category: Health Questionnaire

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