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The University of Michigan Health Management Resource Center
Health Risk Appraisal Profile
HMRC Version
this Health Risk Appraisal and return to the Health Dashboard.

Complete each question as best you can, by indicating the best response. This Health Risk Appraisal is not designed for people who already have Heart disease, Cancer, Kidney disease, or other serious conditions.

Your results will be kept strictly confidential.

1 AUTHORIZATION Confirmed

2 SEX Male

3 AGE (At last birthday) 37 years old

4 Are you pregnant?

5 HEIGHT (without shoes) 6 feet 1 inches

6 WEIGHT (without shoes) 167 pounds

7 What is your blood pressure now? Systolic (high number)
Diastolic (low number)
I'm not sure

8 What is your total cholesterol level? (based on a blood test)
I'm not sure

9 What is your HDL cholesterol level? (based on a blood test)
If you do not know the number, which best describes your HDL cholesterol?


10 cigarette SMOKING
How would you describe your cigarette smoking habits?		 Never Smoked

11 STILL SMOKE cigarettes per day

12 for Former cigarette Smokers Only Not applicable

13 Do you smoke or use pipes?
cigarettes?
smokeless tobacco?

14 How often do you use drugs or medication (including prescription drugs) which affect your mood or help you to relax?

15 How many drinks of alcoholic beverages do you have in a typical week?
(one drink = one beer, glass of wine, shot of liquor or mixed drink.)		 drinks

16 How many times in the last month did you drive or ride when the driver had perhaps too much to drink? times last month

17 In the next 12 months how many thousands of miles will you probably drive or ride by each of the following?
A. Car, truck, van or SUV
B. Motorcycle

18 What percent of the time do you usually buckle your safety belt when driving or riding?

19 On the average, how close to the speed limit do you usually drive?

20 On a typical day how do you usually travel?

21 How many servings of foods do you eat that are high in fiber, such as whole grain bread, high fiber cereal, fresh fruits or vegetables? (serving size: 1 slice bread, 1/2 cup or 110 ml vegetables, 1 medium fruit, 3/4 cup or 170 ml cereal)

22 How many servings of foods do you eat that are high in cholesterol or fat such as fatty meat, cheese, fried foods or eggs? (serving size: 3 1/2 oz or 100 g meat, 1 egg, 1 oz/slice or 28 g cheese)

23 In the average week, how many times do you engage in physical activity (exercise or work which is hard enough to make you breathe more heavily and to make your heart beat faster) and is done for at least 20 minutes? Examples include running, brisk walking or heavy labor, e.g. chopping, lifting, digging, etc.

Quality of Life Indicators

24 In general, how satisfied are you with your life? (include personal and professional aspects)

25 Would you agree you are satisfied with your job?

26 In general, how strong are your social ties with your family and/or friends?

27 Considering your age, how would you describe your overall physical health?

28 How many hours of sleep do you usually get at night?

29 Have you suffered a personal loss or misfortune in the past year? (For example: a job loss, disability, divorce, separation, jail term, or the death of someone close to you)

30 How often do you feel tense, anxious, or depressed?

31 During the past year, how much effect has stress had on your health?

32 In the past year, how many days of work have you missed due to personal illness?

33 During the past 4 weeks how much did your health problems affect your productivity while you were working?

34 How many hours did you take off from work over the past 2 weeks to take care of sick children, parents or other relatives? (This might include taking children to doctor's appointments, staying home with a sick child or parent or calling doctors or health insurance companies.) hours

Medical History and Self-Care

35 Do you have a family history (brother, sister, mother, father, grandparents) of: High blood pressure

Heart problems

Diabetes

Cancer

High cholesterol


36 Do you have: If you have currently are you:
Allergies Taking medication Under medical care
Arthritis Taking medication Under medical care
Asthma Taking medication Under medical care
Back pain Taking medication Under medical care
Cancer Taking medication Under medical care
Chronic bronchitis / emphysema Taking medication Under medical care
Chronic pain Taking medication Under medical care
Depression Taking medication Under medical care
Diabetes Taking medication Under medical care
Heart problems Taking medication Under medical care
Heartburn or acid reflux Taking medication Under medical care
High blood pressure Taking medication Under medical care
High cholesterol Taking medication Under medical care
Menopause Taking medication Under medical care
Migraine headaches Taking medication Under medical care
Osteoporosis Taking medication Under medical care
Stroke Taking medication Under medical care
Other condition Taking medication Under medical care

37 When was the last time you had these preventive services or health screenings?
Colon cancer screen
Rectal exam
Flu shot
Tetanus shot
Blood pressure
Cholesterol
for Men Only
Prostate exam

38 In the past 12 months, how many times have you:


Visited a physician's
office or clinic
 
Gone to the
emergency room
 

Stayed overnight
in a hospital

 

Used a toll-free number
for medical advice

 
Used a self-care book
 

Been treated with
alternative medicine


Personal Information

45 Current marital status

46 Race/Origin

47 Which is the highest level of education you have achieved?

48 Expected household income this year?


Health Planning Questions

49 In the next 6 months, are you planning to make any changes to keep yourself healthy or improve your health?

Increase physical
activity

 
Lose weight
 
Reduce alcohol use
 

Quit or cut down
smoking

 
Reduce fat/
cholesterol intake
 
Lower blood pressure
 
Lower cholesterol level
 
Cope better with stress

50 In the next 6 months, would you participate in a program that would help you to enhance your overall health?

51
If available, would you like follow-up information and other services?

 

 
 
 
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