By completing this assessment, I agree to share this information with my provider and agree to an e-visit if necessary.
Health Risks
1
Physical Activity
In the past 7 days, how many days did you exercise? days
0
1
2
3
4
5
6
7
2
Tobacco Use
In the last 30 days, have you used tobacco in any form?
Yes
No
3
Alcohol Use
In the past 7 days, how many drinks have you had that contain alcohol?
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14+
4
Seat Belt Use
Do you always fasten your seat belt when you are in a car? Y/N
Yes
No
5
Life satisfaction
In the past 2 weeks, how often have you felt down, depressed, or hopeless?
Almost all of the time
Most of the time
Some of the time
Almost never
6
Anxiety
In the past 2 weeks, how often have you felt nervous, anxious, or on edge?
Almost all of the time
Most of the time
Some of the time
Almost never
7
Stress
How often is stress a problem for you in handling such things such as health, finances, family or social relationships or work?
Never or rarely
Sometimes
Often
Always
8
Pain
In the past 7 days, how much pain have you felt?
None
Some
A lot
9
General Health
In general, would you say your health is
Excellent
Very good
Good
Fair
Poor
10
Sleep
Each night, how many hours of sleep do you usually get?
0
1
2
3
4
5
6
7
8
9
10
11
12+
Biometric Measures— Self-Reported
11
Blood Pressure
If your blood pressure was checked within the past year, what was it when it was last checked?
Low or normal (at or below 120/80)
Borderline high (120/80 to 139/89)
High (140/90 or higher)
Don’t know/not sure
12
Cholesterol
If your cholesterol was checked within the past year, what was your total cholesterol when it was last checked?
Desirable (below 200)
Borderline high (200–239)
High (240 or higher)
Don’t know/not sure
13
Blood Glucose
If your glucose was checked, what was your fasting blood glucose (blood sugar) level the last time it was checked?
Desirable (below 100)
Borderline high (100–125)
High (126 or higher)
Don’t know/not sure
14
Hemoglobin A1c level
If diabetic, and if you have had your hemoglobin A1c level checked in the past year, what was it the last time you had it checked?
Desirable (6 or lower)
Borderline high (7)
High (8 or higher)
Not a Diabetic
Don’t know/not sure
15
Overweight/Obesity
What is your height?
Feet
0
1
2
3
4
5
6
7
8
9
10
Inches
0
1
2
3
4
5
6
7
8
9
10
11
Weight in pounds
BMI :
16
In the past 2 years have you experienced any allergies of any type?
Yes
No
17
When was the last visit with our Group?
Don’t Remember
Prior to last year
This current year
Date
18
In the past year have you been to an Urgent Care Facility?
Yes
No
Don’t Remember
Date
19
In the past year have you been to a Hospital Emergency Room?
Yes
No
Don’t Remember
Date
Important Notification:
By completing and submitting any assessment you give consent for an e-visit and a co-pay may or may not apply.
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