Difference between revisions of "CDC Health Risk Assessments"
| Line 20: | Line 20: | ||
'''Tobacco Use''' | '''Tobacco Use''' | ||
| − | |||
4. In the last 30 days, have you used tobacco? | 4. In the last 30 days, have you used tobacco? | ||
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5. Used a smokeless tobacco product: □ yes □ no | 5. Used a smokeless tobacco product: □ yes □ no | ||
| − | 6. If yes to either, would you be interested in quitting? | + | 6. If yes to either, would you be interested in quitting tobacco use within the next month? □ yes □ no |
'''Alcohol Use''' | '''Alcohol Use''' | ||
| − | 7. In the past 7 days, how many days did you drink alcohol? | + | 7. In the past 7 days, how many days did you drink alcohol? ____ days |
| − | 8. On days when you drank alcohol, how often did you have | + | 8. On days when you drank alcohol, how often did you have ____ (5 or more for men, 4 or more for women and those men and women 65 years or over) alcohol drinks on one occasion? |
| + | |||
| + | □ Never | ||
| + | |||
| + | □ Once during the week | ||
| + | |||
| + | □ 2-3 times during the week | ||
| + | |||
| + | □ More than 3 times during the week | ||
9. Did you ever drive after drinking, or ride with a driver who had been drinking? | 9. Did you ever drive after drinking, or ride with a driver who had been drinking? | ||
Revision as of 09:21, 28 April 2015
The CDC Health Risk Assessment is a patient assessment developed for the Medicare Annual Wellness Visit.
Physical Activity
1. In the past 7 days, how many days did you exercise? ____ days
2. On days when you exercised, for how long did you exercise (in minutes) ___ minutes per day □ Does not apply
3. How intense was your typical exercise? (select one)
□ I am currently not exercising
□ Light (like stretching or slow walking)
□ Moderate (like brisk walking)
□ Heavy (like jogging or swimming)
□ Very heavy (like fast running or stair climbing)
Tobacco Use
4. In the last 30 days, have you used tobacco?
Smoked: □ yes □ no
5. Used a smokeless tobacco product: □ yes □ no
6. If yes to either, would you be interested in quitting tobacco use within the next month? □ yes □ no
Alcohol Use
7. In the past 7 days, how many days did you drink alcohol? ____ days
8. On days when you drank alcohol, how often did you have ____ (5 or more for men, 4 or more for women and those men and women 65 years or over) alcohol drinks on one occasion?
□ Never
□ Once during the week
□ 2-3 times during the week
□ More than 3 times during the week
9. Did you ever drive after drinking, or ride with a driver who had been drinking?
Nutrition
10. In the past 7 days, how many servings of fruit and vegetables do you eat per day? (1 serving = 1 cup fresh vegetables, 1/2 cup cooked vegetables, or 1 medium piece of fruit)
11. In the past 7 days, how many servings of high fiber or whole grains food do you eat per day? (1 serving = 1 slice of whole wheat bread, 1 cup of whole grain or high-fiber cereal, 1/2 cup of cooked cereal oatmeal, 1/2 cup of brown rice or whole wheat pasta)
12. In the past 7 days, how many servings of fried or high-fat foods did you typically eat each day? (Examples: fried chicken, fried fish, bacon, french fries, potato chips, corn chips, doughnuts, creamy salad dressing, foods made with milk, cream, cheese, or mayonnaise)
13. In the past 7 days, how many sugar-sweetened (not diet) beverages did you consume each day?
Seat Belt Use
14. Do you always fasten your seat belt when you are in the car?
Depression
15. 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
16. In the past 2 weeks, how often have you felt little interest or pleasure in doing things?
- Almost all of the time
- Most of the time
- Some of the time
- Almost never
17. Have your feeling caused you distress or interfered with your ability to get along socially with family or friends?
Anxiety 18. 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
19. In the past 2 weeks, how often were you not able to stop worrying or control your worrying?
- Almost all of the time
- Most of the time
- Some of the time
- Almost never
High Stress
20. How often is stress a problem for you in handling such things as: Your health? Your finances? Your family or social relationships? Your work?
- Never or rarely
- Sometimes
- Often
- Always
Social/Emotional Support
21. How often do you get the social and emotional support you need:
- Always
- Usually
- Sometimes
- Rarely
- Never
Pain
22. In the past 7 days, how much pain have you felt?
- None
- Some
- A lot
General Health
23. In general, would you say your health is
- Excellent
- Very Good
- Good
- Fair
- Poor
24. How would you describe the condition of your mouth and teeth - including false teeth or dentures?
- Excellent
- Very Good
- Good
- Fair
- Poor
Activities of Daily Living
25. In the past 7 days, did you need help from others to perform everyday activities such as eating, getting dressed, grooming, bathing, walking or use of the toilet?
Instrumental Activities of Daily Living
26. In the past 7 days, did you need help from others to take care of things such as laundry, housekeeping, banking shopping, using telephone, food preparation, transportation or taking your medications?
Sleep
27. Each night, how many hours of sleep do you usually get?
28. Do you snore or has anyone told you that you snore?
29. In the past 7 days, how often have you felt sleepy during the daytime?
- Always
- Usually
- Sometimes
- Rarely
- Never
Blood Pressure
30. If your blood pressure was checked within the past year, what was it?
- Low or normal (at or below 120/80)
- Borderline high (120/80 ro 139/89)
- High (140/90 or higher)
- Don't know/not sure
Cholesterol
31. If your cholesterol was checked within the past year, what was it?
- Desirable (below 200)
- Borderline high (200-239)
- High (240 or higher)
- Don't know/not sure
Blood Glucose
32. If your glucose was checked, what was your fasting blood glucose (blood sugar) level the last time it was cheched?
- Desirable (below 100)
- Borderline high (100-125)
- High (126 or higher)
- Don't know/not sure
