Directions: This page is coded to indicate likely categories of risk for the health assessment. Genetic or hereditary risk is coded as (H); environmental risk as (E); behavioral risk as (B); access to care as (AC).
1. What is your age in years? 55
2. What is your race? White ___ Black _X__ Hispanic ____ Other: _______ (H)
3. What is your gender? Male __X__ Female ____ (H)
4. What is your occupation? Technician at the Oak Ridge Nuclear Plant (E)
5. Would you describe your health as good, fair, or poor? Fair
6. Do you have any specific health concerns? I often feel weak and trembly, sometimes dizzy, and I get headaches; I've lost weight lately and I haven't been trying to do so; I have a rash on my arms and chest; some of my buddies at work have some of the same symptoms
6. Have you had a medical examination within the past five years? Yes ____ No __X__ (AC)
7. Are you under a doctor's care for any diagnosed condition? no (AC)
8. Are you taking prescription medications? no (AC)
9. What was your last B/P (blood pressure) reading? 170/110, at a free screening at a local street fair (AC)
10. Do you have a family history of any of the following? Heart attack before age 50: yes, father and uncle (H) Stroke: yes, father, uncle and brother (H)
11. Do you use tobacco in any form? Yes, smoke cigarettes (B) If yes, how much do you use? Smoke about a pack a day (B)
12. Do you routinely participate in vigorous exercise for 20 minutes at least three times a week? no (B)
13. Do you keep a firearm in your home? yes (B)
14. Do you eat an average of five fruits and vegetables each day? no (B)
15. How often do you eat fried foods? About every day (B)
16. How often do you eat at "fast food" restaurants? About 3 or 4 times a week (B)