HEALTH ASSESSMENT QUESTIONNAIRE

I. Basic Information
Name__________________________________ Cell Phone No.________________________ Home Address _______________________________________________________________ Date of Birth ______________ Age_______ Sex______ Weight ________ Height _______ Occupation: Current __________________________________________________________

II. Health Indicators

Direction: Fill in your answer(s) on the space provided or check the option that correspond to your answer. 1. What is your latest blood pressure reading? ___________________ 2. Did you have your blood cholesterol level checked a month ago? ____ I have not had a latest cholesterol screening test. ____ Yes If yes, what was your latest cholesterol level? _______________ If you do not know the number, which best described your cholesterol level? ____High ____Normal ____Low ____Im not sure 3. Did you have your blood sugar level checked a month ago? ____ I have not had a latest blood sugar screening test. ____ Yes If yes, what is your blood sugar level? _______________ If you do not know the number, which best described your blood sugar level? ____High ____Normal ____Low ____Im not sure

III.

Health-Related Behaviors 1. Cigarette Smoking How would you describe your smoking habit? ____Still smoke (Please proceed to question number 2) ____Used to smoke (Please proceed to question number 3) ____Never smoked (If you answered this option, please skip questions 2 & 3) 2. Still Smoke How many cigarettes per day? ____ 1 5 sticks per day ____ 6 10 sticks per day ____ More than 1 pack per day 3. Used To Smoke How many years has it been since you smoked cigarette on a fairly regular basis? ____ 1 5 years ____ 6 10 years ____ More than 10 years What was the average number of cigarettes per day that you smoked before you quitted? ____ 1 5 sticks per day ____ 6- 10 sticks per day ____ More than 1 pack per day 4. Do you drink alcoholic beverages? ____ No (If no, please skip question no. 6) ____ Yes If yes, how often? ____ Everyday ____ Every weekends ____ During occasions

5. Do you eat a balanced diet (i.e., protein, fresh fruits, grains, vegetables, & cultured dairy)? ____ Often ____ Sometimes ____ Rarely ____ Never 6. Do you often engage in? ____ Moderate activity (e.g. walking, biking, cycling, calisthenics) ____ Vigorous activity (e.g. jogging, running, backpacking, mountain climbing) ____ None at all

IV.

Medical History And Self Care 1. Do you have a family history of: ____High Blood pressure ____Heart problems ____Diabetes ____Cancer ____High Cholesterol Level ____Others, please specify ___________________________________ 2. Have you had: ____Hearth problems ____Diabetes ____Cancer ____Chronic Bronchitis/emphysema ____Past stroke ____Asthma ____Arthritis ____Allergies ____Back pain ____Others, please specify ___________________________________

V. Health Planning Questions

1. What changes have you made to enhance your health during the past 12 months? ____Increased physical activity ____Lost weight ____Reduced alcohol use ____Quit or cut down smoking ____Reduced fat/cholesterol intake ____Lowered blood pressure ____Lowered cholesterol level ____Lowered blood sugar level ____Coped better with stress ____Others, please specify ___________________________________

2. What changes do you plan to undertake to keep yourself healthy or improve your health in the next 6 months? ____Exercise regularly ____Lose weight ____Reduce alcohol use ____Quit or cut down smoking ____Optimize diet control ____Lower blood pressure ____Lower cholesterol level ____Lower blood sugar level ____Maintain improved coping strategies ____Others, please specify ___________________________________