Health Risk Assessment Questionnaire

Spot the habits and conditions that raise the odds of illness: sleep, diet, tobacco, alcohol, exercise and mental wellbeing. Preventive medicine and occupational health programmes use it to sort people by risk level. The whole set of answers fits on a single screen.

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Full name

Nombre

Apellido

Date of birth

Do you consider yourself a healthy person?

Yes More or less No

How satisfied are you with your life?

Very happy Happy Neither happy nor unhappy Unhappy Very unhappy

How often do you do physical activity?

Never One or two times a week Three or four times a week Five or six times a week Every day

Do you wear a seat belt?

Always Usually Sometimes Never

Do you sleep well?

Yes Sometimes No

Do you follow a healthy diet?

Yes Mostly No

Do you smoke cigarettes?

Yes, daily Occasionally I used to smoke Never

How often do you drink alcohol?

I do not drink Occasionally A few times a month Weekly Daily

Do you have any of these chronic diseases?

Diabetes High blood pressure Heart disease Asthma Cancer Arthritis None of these

Do you have any infectious or sexually transmitted disease?

Yes No Prefer not to say

Do you have any disability?

Yes No

Are there relevant medical conditions in your family?

Yes No Not sure

Do you have any of these mental or emotional health conditions?

Anxiety Depression Bipolar disorder Post-traumatic stress Eating disorder None of these

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