Health Assessment Questionaire Name * First Name Last Name Phone Number * (###) ### #### Email 1. Date of birth * MM DD YYYY 2. Ethnicity (mark all that apply) * White Hispanic Alaskan Native Black/African American Native American South East Asian Asian/Pacific Islander Mid-East/Asian Indian Other 3. Gender * Male Female 4. Marital Status * Married, spouse in household Married, spouse not in household Living as married/domestic partner Widowed Divorced Separated Never married 5. Educational Level * High School GED Some College, no degree Associates Degree Bachelor’s Degree Some Post Bachelor’s classes Master’s Degree Doctorate Degree Post Doctorate Degree 6. Are you currently employed as a firefighter? * Yes No* *If No - Year Retired: 7. Year of Hire * 8. Have you ever left for more then 6 months * Yes* No *If Yes, how many months? 9. Do you currently work at another job? * Yes* No *If Yes, how many hours a week? 10. Current primary assignment * Admin Operations Since? * MM DD YYYY 11. How many stations have you been assigned to for more that one year? * 12. Please estimate how many days of non-work-related sick leave (including dependent care) you have taken in the past year * 13. Please estimate how many Industrial Injury hours you have had in the past year * 14. In the past year have you been on Light Duty prior to returning to full duty? * Yes* No *If Yes, how many days? 15. In the past year have you been placed on Long Term or Permanent alternative duty? * No Yes, Long Term* Yes, Permanent* If Yes, give an approximate timeline 16. Have you smoked at least 100 cigarettes (5 packs) in your entire life? * Yes No (skip to question 20) 17. About how many cigarettes do you (or did you) usually smoke per day? If less than 1 per day, enter 0; If 95 or more per day, enter 95 (1 pack = 20 cigarettes) 18. For about how many years have you smoked (or did you smoke) this amount? If less than 1 year, enter 0 19. How often do you smoke now? Every day Some days Not at all 20. Please list any tobacco products that you currently use and how often 21. During the past 12 months, have you stopped using tobacco for one day or longer because you were trying to quit? No Yes* If Yes, number of days you quit 22. Were you enrolled in a tobacco cessation program this year? * Yes No 23. During the past 30 days, have you had at least one drink of any alcoholic beverage such as beer, wine, a malt beverage, or liquor? * Yes No (skip to question 26) 24. During the past 30 days, how many days did you have at least one drink of an alcoholic beverage? 25. During the past 30 days, on the days when you drank, about how many drinks did you drink on average? 26. Do you have a male parent, sibling, or offspring who was diagnosed with a heart attack, angina, or coronary heart disease at an age than 55 years old? * Yes No 27. Do you have a female parent, sibling, or offspring who was diagnosed with a heart attack, than 55 years old? angina, or coronary heart disease at an age younger than 55 years old? * Yes No 28. Do you have a male parent, sibling, or offspring who was diagnosed with cancer? * No Yes* If Yes, what were they diagnosed with? 29. Do you have a female parent, sibling, or offspring who was diagnosed with cancer? * No Yes* If Yes, what were they diagnosed with? 30. Do you have a grandparent, parent, sibling, or offspring who was diagnosed with diabetes? * Yes No 31. Please indicate if you have any chronic health problems, how recently you were diagnosed, and whether you are taking any medication for it 32. Please describe any surgeries you have had and an approximate year 33. We would like to ask about screening tests you have had in the past year, and whether results were normal or required follow-up. 34. On the average, over the last month, how many days each week did you get at least 30 minutes of exercise? * Exercise is physical activity that causes you to increase your heart rate, breathe harder, or sweat. 35. How many days per week did you exercise or take part in cardiovascular or aerobic activities that made you sweat and breathe hard for at least 30 minutes? * Examples: basketball, tennis, jogging, fast bicycling etc. 36. How many days per week did you exercise to strengthen or tone your muscles? * Examples: weight lifting, kettlebell training, core training, functional training, etc. 37. In a typical week, how many days do you take part in any physical activity long enough to work up at sweat. * 38. I exercise for 30 minutes almost every day. * Strongly Disagree Disagree Neutral Agree Strongly Agree 39. Please list any vitamins or supplements that you take 40. Additional information you would like to convey or discuss during this visit? We will need a copy of your insurance card at your upcoming appointment! * Yes, I will bring my insurance card to my appointment Thank you! Your form has been submitted
