Health Risk Questionnaire

Age and email address are required fields. The former is needed in order to be able to correctly provide more accurate assessment of your health risk(s). The latter is needed to be able to email you your results. Your email address will not be used for any other reason (please see our privacy policy).

Personal Information:

First name:
Last name:
Age:
Date of birth (DD/MMM/YYYY):    
Email address:
Confirm email address:

I give CitaHealth permission to contact me, by email, on health and fitness topics.
Yes
No

Questionnaire

General

1. Please choose the appropriate response regarding your smoking status:
I have never smoked.
I quit smoking more than 10 years ago.
I quit smoking less than 10 years ago.
I smoke less than 10 cigarettes per day.
I smoke more than 10 cigarettes per day.

2. I have had a grandparent, parent, brother, or sister suffer from a heart attack or die suddenly before age 55:
Yes
No

If yes, please explain who it was, what the event was, and what age they were:

3. My physician is currently prescribing medication or some form of treatment for high blood pressure or a heart condition:
Yes
No

4. My physician has informed me that I have a high blood cholesterol level:
Yes
No

5. I feel pain in my chest when I perform physical work or participate in a physical activity:
Yes
No

6. A physician has diagnosed me with Diabetes:
Yes
No


Physical Activity Participation

7. In a typical week (7 days), I am sufficiently physically active to increase my heart rate and cause perspiration:
(If Aerobic: Heart rate greater than 70 % of maximum (220-age) for at least 20 minutes; If Muscular: Working major muscle groups of body at least 1-2 sets of 12-15 reps.)
More than 3 times per week
1-3 times per week
Less than 1 time per week

8. When I participate in physical activity, I would describe the intensity of my effort as:
(If Aerobic: Heart rate greater than __ % of maximum; If Muscular: Resistance Training using a resistance which makes you fatigue around ____ reps, and/or rest intervals between sets ____ seconds.)
Intense (A = 80, M = 8-10, 45-60)
Moderate (A = 75, M = 10-15, 60-75)
Light (A = 70, M = 15-20, 75-90)

Note: Aerobic: biking, jogging, hiking, swimming etc. Muscular: Weights, Universal, Nautilus, Bowflex. If you do not do any of these, then use a personal rating for how intense you perform physical activity.

9. Generally, I consider my present physical fitness to be:
very good
good
average
poor
very poor

10. Considering my knowledge and understanding of my body's physical activity needs as I age:
I am very knowledgeable.
I have a basic understanding.
I understand somewhat and require groups or classes to meet my needs.
I have very little knowledge of my body's requirements and do not consider myself capable of planning my activity safely or effectively.


Dietary Considerations and Eating Habits

11. I know or feel that I am within ___lbs. of my healthy weight.
not within 20 lbs. (8 kg)
20 lbs. (8 kg)
15 lbs. (6 kg)
10 lbs. (4 kg)
5 lbs. (2 kg)

12. I eat red meat:
never
1-2 times per week
3-4 times per week
every day
more than once/day

13. I eat convenience/fast foods and/or snack foods (chips, chocolate bars, muffins, donuts, etc.):
never
1-2 times per week
3-4 times per week
every day
more than once/day

14. Consider the recommended daily servings of the four food groups as defined by Canada's Food Guide:
> Grain Products - 5-12 servings
> Fruits and vegetables - 5-10 servings
> Meat and alternatives - 2-3 servings
> Milk and milk products - 2-4 servings

I generally eat:
less than the recommended servings of one or more of the 4 food groups.
the recommended servings of all 4 food groups.
An unbalanced diet; more than the recommended servings of one or more food groups and less than the recommended servings of others.

15. I eat a balanced breakfast before starting my day:
never
1-2 times per week
3-4 times per week
5-6 times per week
daily

16. I consume ___ alcoholic drinks/week (1 drink is 12 oz beer, 3-4 oz wine, or 1 oz liquor):
0 (none)
less than 7
7-9
10-14
more than 14

17. I add a fat-rich garnishing to my meals (butter/margarine, mayonnaise, sour cream, salad dressing):
never
rarely
occasionally
often
regularly

18. I drink ___ cups of water/day.
0-2
3-5
6-8
more than 8

19. I drink ___ cups of coffee, tea or other caffeine-containing beverage each day.
0
1-2
3-4
more than 4


Lifestyle

20. I am able to talk to someone about matters that are important to me:
never
seldom
some of the time
fairly often
almost always

21. I think positively and consider myself optimistic:
never
seldom
some of the time
fairly often
almost always

22. I feel anxious or uptight:
never
rarely
some of the time
often
on a regular basis

23. I feel sad or depressed:
never
rarely
some of the time
often
on a regular basis

24. I get sufficient sleep to feel rested:
never
1-2 times per week
3-4 times per week
5-6 times per week
daily

25. I enjoy relaxation time:
never
rarely
some of the time
often
on a regular basis