Your Health Risk Assessment and Biometric Screening

Transcription

1 Your Health Risk Assessment and Biometric Screening Below is information to help you prepare for your health risk assessment and biometric screening along with what you can expect on the day of your screening. Complete your health risk assessment questionnaire before your screening appointment. This will take about 15 minutes. o Use a pencil to answer the questions o Fill in the circle that represents your answer o Return your completed questionnaire to Unity one week prior to your biometric screening appointment Plan ahead for your biometric screening appointment o Do not eat or drink anything other than water for 12 hours prior to your appointment o Drink water and be well hydrated during the 12 hour fast o Take all of your medications as directed except for medications taken with food. Bring medications that you take with food to your appointment o Wear clothing that will allow for blood pressure measurement above the elbow without binding o Be on time so that all who have signed up can be served at the requested time o Avoid vigorous exercise or nicotine four hours before your appointment o Avoid applying hand lotion the morning of your health screening as it may interfere with the blood analysis of the finger stick What to expect at your screening o Full Lipid panel which includes Total, HDL (good) LDL (bad) cholesterols, Triglycerides plus Glucose (blood sugar) through a finger stick o Blood pressure measurement o Body Mass Index (BMI) Your Biometric Screening Appointment Your appointment is scheduled for: Day/Date: Time: Location: If you have any questions or concerns, please contact Unity s Wellness Representatives through Ask an Expert within MyChart at unitymychart.com or call

2 Health Risk Assessment Last Name MI First Name Date of Birth (m/dd/yyyy) / / Female Male Subscriber Number (This is the nine digit subscriber number found on your ID card.) Please Note: If you are not a Unity member, enter N/A for the subscriber number. Employer Name Please Note: If you are completing this for an employer other than your own, please list that employer s name. Street Address City State Zip Code Phone Number Disclaimer 1.1) Read the Terms of Use, below, describing how your personal information will be safeguarded and used to develop your report. Health Assessment Notice to End Users Congratulations for choosing to participate in the Health Assessment. Consider this assessment as your first step to better health. By choosing to take personal responsibility for your good health now, you may live a longer, healthier, and happier life. This assessment is designed for adults 18 years or older. Use of Personal Information. This site retains the information you submit in the course of taking the Health Assessment. This sets forth the site s practices regarding the information it collects from Personal Wellness Profile participants. Your answers to the questionnaire will be disclosed in aggregate form. By aggregate form, we mean that your data will be combined with those of other participants in a manner which does not personally identify you. This site has taken steps to fully comply with laws and regulations on the use of personal information; however, this site does not ultimately control the privacy and security practices of licensees of the aggregate data. Additionally, in the course of providing services associated with the Health Assessment and other products, your health and wellness providers may have access to your personal information. You may delete your Wellness Profile at any time; however, we cannot guarantee that your information in aggregate form will be completely removed from the system. Terms of Use. By participating in the Health Assessment, you agree that the results of the assessment will be used for instructive purposes only and that the Health Assessment is not intended to and cannot replace the advice of a medical professional. You should not rely on the Health Assessment for diagnosis or treatment. All people who display disease symptoms fall into certain high risk categories, and/or who receive abnormal laboratory test results should consult a physician before embarking on any course of action or any lifestyle change. This site is not liable for any health consequences resulting from your participation in this program. Consent. This policy and notice may change at any time. This notice contains our policy with respect to our security and privacy practices. By signing below, I acknowledge that I have read, understand, and agree to the above and assert that I am at least 18 years of age. I AGREE TO THE TERMS OF USE X Signature Date For Office Use Only Date entered: Entered by: Date audited: Audited by: Unity s Wellness Representatives: Call: Fax: Send completed forms to: Unity Health Insurance, 840 Carolina Street, Sauk City, WI Page 1 of 12

3 Please complete the entire questionnaire by fully shading in the appropriate circle based on your answer. Please note: If any information is left blank, the questionnaire will be returned to you. General Health 1.2) Complete the following statement: "In general, my overall health is..." a) excellent b) very good c) good d) fair e) poor Your Current Health 1.3) Do you have, or have you been told that you have any of the following health conditions: (Fill in all that apply or leave blank if not applicable) a) stroke b) asthma c) diabetes d) arthritis e) back pain f) depression g) osteoporosis h) high cholesterol i) cancer j) high blood pressure k) chronic bronchitis, COPD l) angina, congestive heart failure or heart attack m) heartburn Page 2 of 12

4 Preventive Health 2.1) When was your last physical? Males under age 50 - skip to question 2.13 Males age 50 and older - skip to question ) When was your last pap smear? (Leave blank if you can t remember) 2.3) Have you ever had an abnormal pap smear? If you answered no, skip to ) Did you follow up as recommended by your provider? 2.5) Have you had HPV testing done in combination with your pap smear in the last 5 years? c) not sure 2.6) Do you take a folate supplement or multivitamin? Females under age 40 - skip to question ) Have you ever had a mammogram? c) not applicable 2.8) When was your last mammogram? (Leave blank if not applicable) 2.9) Do you have a mammogram performed yearly? c) not applicable / Month Year / Month Year / Month Year Page 3 of 12

5 Preventive Health 2.10) Do you receive at least 1200 mg/day of calcium? c) not sure Females under age 50 - skip to question ) Have you ever had a colonoscopy or other colon cancer screening tests? Females - skip to question ) Have you ever had a PSA test to screen for prostate cancer? c) not applicable 2.13) Have you had a flu shot in the last 12 months? Breakfast 3.1) How often do you eat breakfast, more than just a roll and a cup of coffee? a) eat breakfast every day b) eat breakfast most mornings c) eat breakfast two or three times per week d) seldom or never eat breakfast Snacks 3.2) How often do you eat snack foods between meals (chips, pastries, soft drinks, candy, ice cream, cookies)? a) three or more times per day b) once or twice per day c) few times per week d) seldom or never eat typical snacks Salt 3.3) How often do you add salt to your food or eat salty foods (chips, pickles, soy sauce)? a) seldom or never b) some meals c) most meals d) nearly every meal Page 4 of 12

6 Fat Intake 3.4) Indicate the kinds of foods you usually eat High-Fat Examples Low-Fat Examples hamburgers cheese lean meats fruit desserts hot dogs whole milk skinless poultry gelatin bologna eggs fish vegetables steaks butter skim milk pasta sour cream cake low-fat dairy products a) nearly always eat high-fat foods b) eat mostly the high-fat foods, some low-fat c) eat both about the same d) eat mostly low-fat foods, some high-fat e) eat only low-fat foods Breads and Grains 3.5) Indicate the kinds of breads and grains you usually eat. Refined Grain Examples Whole-Grain Examples white bread whole-grain breads white rolls brown rice regular pancakes and waffles oatmeal and many other cooked cereals white rice whole-grain or high-fiber cereals typical breakfast cereals typical baked goods a) nearly always eat refined grain products b) eat mostly refined grain products, some whole-grain c) eat both about the same d) eat primarily whole-grain products, some refined e) eat only whole-grain products Fruits and Vegetables 3.6) How many servings of fruits and vegetables do you eat daily? (one serving = 1 cup fresh, ½ cup cooked, 1 medium size fruit, or ¾ cup juice). a) one or less b) two daily c) three daily d) four daily e) five or more daily Page 5 of 12

7 Sweets and Desserts 3.7) How many servings of cookies, cakes, donuts, candy, soda, or packets of sugar do you eat daily? a) one or less b) two daily c) three daily d) four daily e) five or more daily Physical Activity 4.1) How many days per week do you participate in at least minutes of physical activity? Moderate = brisk walk, enough to break a light sweat, but without becoming winded. Vigorous = running, enough to break a heavy sweat and experience heavy breathing. a) none b) one day of moderate exercise c) two days of moderate exercise d) three days of moderate OR 1 day of vigorous exercise e) four days of moderate OR 2 days of vigorous exercise f) five days of moderate OR 3 days of vigorous exercise g) six days of moderate OR 4 days of vigorous exercise h) seven days of moderate OR more than 4 days of vigorous exercise Strength Exercises 4.2) How many days a week do you engage in strength training exercises. a) none b) once a week c) twice a week d) three or more times a week Stretching Exercises 4.3) How many times per week do you do stretching exercises to improve the flexibility of your back, neck, shoulders, and legs? a) none b) once a week c) twice a week d) three or more times a week Emotional Health 5.1) During the last 2 weeks has feeling down, depressed or hopeless bothered you? Page 6 of 12

8 Emotional Health 5.2) During the last 2 weeks, has little interest or little pleasure in doing things bothered you? If you answered no to either 5.1 or 5.2, skip to ) Do you have a history of depression? 5.4) In the past 6 months have you thought of hurting yourself? 5.5) Do you have a suicide plan? Emotional Problems 5.6) In the past month, have you felt any of the following? (select all that apply) a) downhearted or sad b) angry or hostile c) nervous or uptight d) that you are receiving good support from friends and family e) that interesting and challenging situations fill your life Social Activity 5.7) During the past four weeks, to what extent has your physical health or an emotional problem interfered with your normal activities with family, friends, neighbors, or groups? a) none at all b) slightly c) moderately d) quite a bit e) extremely Coping Status 5.8) How well do you feel you are coping with your current stress load? a) coping very well b) coping fairly well c) have trouble coping at times d) often have trouble coping e) feel unable to cope Page 7 of 12

9 Coping Status 5.9) Do you have good support from your family and friends? 5.10)During the past year have you had any major life or work changes? Stress Signals 5.11)Select any item below that applies to you: (Fill in all that apply) a) minor problems overwhelm me b) find it difficult to get along with people c) nothing seems to give me pleasure anymore d) unable to stop thinking about my problems e) feel frustrated, impatient, or angry much of the time f) feel tense or anxious much of the time 5.12)Stress reduction techniques (things like exercise, reading, journaling, drawing, meditation, etc.) are useful in managing daily stress. How often do you incorporate stress reduction techniques into your week? a) daily b) most days c) few days d) never Sleep 5.13)How often do you get seven to eight hours of sleep per night? a) always b) most of the time c) less than half the time d) seldom or never Automotive 6.1) Do you wear a seatbelt in the car? Page 8 of 12

10 Automotive 6.2) How often do you wear a seatbelt? a) always b) most of the time c) less than half the time d) seldom or never Home 6.3) Do you have a smoke detector in your home? c) unsure 6.4) Do you have a carbon monoxide detector in your home? c) unsure Self 6.5) Do you regularly apply sunscreen of SPF 15 or greater? c) sometimes 6.6) Within the last 12 months, have you been in a relationship in which threats, pushing, grabbing, hitting, kicking, breaking things or other harmful behavior was used? Smoking Status 7.1) Select the item below that applies to you: a) have never smoked e) quit smoking 0-5 months ago b) quit smoking two or more years ago f) currently smoke pipe or cigar only c) quit smoking one to two years ago g) currently smoke less than 10 cigarettes daily d) quit smoking 6-12 months ago h) currently smoke 10 or more cigarettes daily Chewing Tobacco 7.2) Do you use chewing tobacco? Page 9 of 12

11 Number of Drinks 8.1) How many alcoholic drinks do you usually consume each week (one drink = a 12 oz. beer or wine cooler, 5 oz. wine, or 1.5 oz. distilled liquor)? a) zero b) one to seven c) 8 to 14 d) 15 to 20 e) 21 or more 8.2) Have you had 5 or more alcoholic drinks in a single sitting in the last 6 months? (A single sitting is defined by the CDC as 2 hours or less.) Drinking and Driving 8.3) Do you ever drive while under the influence of alcohol or do you ever drive with a person who is under the influence of alcohol? Medications and Drugs 8.4) How often do you use drugs or medications (include prescription and non-prescription) that affect your mood, help you relax, or help you sleep? (This question is intended to assess those that are taking medications OTHER THAN daily use medications for the treatment of depression, anxiety or other mental health conditions.) a) frequently b) sometimes c) rarely d) never Indicate how ready you are to make changes or improvements to your health in the following areas NOTE: Fill in one bubble per row for each question. a) Haven t thought about changing b) Plan a change in the next 6 months c) Plan to change this month d) Recently started doing this (0-5 months) 9.1) Be physically active most days 9.2) Eat mostly healthy foods 9.3) Live smoke and tobacco free 9.4) Achieve / maintain healthy weight 9.5) Handle stress well 9.6) Live an overall healthy lifestyle e) Do this regularly (6 months or more) Page 10 of 12

12 Productivity Each of the following questions relates to your last 2 weeks at work: NOTE: Fill in one bubble per row for each question ) How much of the time did your physical or emotional health make it difficult for you to work your scheduled hours? 10.2) How much of the time were you able to sit, stand, or stay in one position while working for over 15 minutes without difficulty caused by physical or emotional health? 10.3) How much of the time did your physical or emotional health make it difficult for you to complete your work? 10.4) How much of the time did your physical or emotional health make it difficult for you to complete your work without mistakes? Cultural and Health Needs and Interests a) None of the time (0%) b) A slight bit of the time Please take a few minutes to complete this survey. Your specific answers will be completely anonymous. To ensure your anonymity, an independent health and wellness partner has been hired to design the survey and process the results. Questionnaires will be processed anonymously, and the findings will be reported in an aggregate format to the organization. a) Strongly Disagree c) Some of the time (about 50%) d) Most of the time e) All of the time (100%) 11.1) Policies and procedures here make it easy to do work 11.2) I am proud to be associated with this company 11.3) Employees are able to support one another 11.4) Management pays careful attention to employee suggestions 11.5) I feel physically safe at my job 11.6) Work-life balance is supported at my company 11.7) Company communications are frequent 11.8) The people at my company always behave in an ethical manner f) Does not apply to my job b) Disagree c) Neutral d) Agree e) Strongly Agree Page 11 of 12

13 Cultural and Health Needs and Interests (Cont.) Indicate how likely you would be to participate in and/or complete each of the following program categories if they were offered by your company s worksite wellness program during the next year. a) Unlikely b) Somewhat c) Neutral d) Likely e) Extremely 12.1) Nutrition 12.2) Weight Management 12.3) Back Care / Ergonomics 12.4) Heart Health 12.5) Self-Care 12.6) Stress / Depression Management 12.7) Physical Fitness / Exercise 12.8) Smoking Cessation 12.9) Biometric Screening Services Worksite Wellness Programs and Services I would be more likely to participate in Worksite Wellness Programs if they were offered: a) Unlikely b) Somewhat c) Neutral d) Likely e) Extremely 12.10) Before Work 12.11) During Work (e.g. Lunch and Learns) 12.12) After Work UH01271 (0413) Unity Health Plans Insurance Corporation Page 12 of 12