Health Risk Factors Assessment

Answering the following questions truthfully and accurately can help estimate your risk of having certain health conditions develop. Your answers will be seen only by the clinical team at ARMC, not by your employer.

Have you ever experienced any of the following events or conditions? (Check all that apply.)

Do you smoke?

Yes

Have you ever smoked?

Yes

Do you have high blood pressure (higher than 140/90)?

Yes

Don't know

Do you take medications for high blood pressure?

Yes

Is your waist measurement more than 35 inches if you are female, or more than 40 inches if you are male?

Yes

Don't know

Do you have a regular doctor?

Yes

Have you ever been told that your cholesterol is high?

Yes

Don't know

Do you always wear your seat belt when riding or driving?

Yes

Do you ever take “street” drugs?

Yes

Do you drink alcohol more than 3 times a week?

Yes

Do you exercise at least twice a week ?

Yes

Do you exercise at least three times a week?

Yes

Are you a diabetic?

Yes

Don't know

Have you ever been told you were borderline diabetic?

Yes

Don't know

Do you have regular check-ups with your doctor?

Yes

Don't know

If you take prescription medicines, do you take them as instructed?

Yes

If you are female, have you ever had gestational diabetes?

Yes

Don't know

If you are female, have you ever had a baby weighing 9 lbs. or more?

Yes

Are you African American, Asian American, Native American, Pacific Islander, or Hispanic American?

Yes

Do you ever have thoughts of suicide?

Yes

Don't know

Do you use tobacco in any form?

Yes

Do you have blood in your urine?

Yes

Don't know

Have you recently had a change in your bowel habits?

Yes

Don't know

Have you recently lost weight without trying to, or had a loss of appetite?

Yes

Do you have problems with balance or walking?

Yes

Do you always feel very tired?

Yes

If female, do you have unusual vaginal bleeding or discharge?

Yes

Don't know

Have you been exposed to asbestos or radon gas?

Yes

Don't know

Do you cough up blood?

Yes

Do you have repeat problems with pneumonia or bronchitis?

Yes

Do you have a lump or thickening in/near breast or underarm area?

Yes

Don't know

Do you have difficulty chewing or swallowing?

Yes

Have you had any overexposure to the sun?

Yes

Don't know

Do you have painful urination?

Yes

Do you have a persistent cough?

Yes

Are you under the care of a cardiologist?

Yes

Do you have blood in your stool?

Yes

Do you have a sore that will not heal?

Yes

Have you noticed a change in size, shape, color or feel of a mole?

Yes

Have you experienced any changes in your speech, vision, or hearing?

Yes

Have you experienced any changes in your mood, personality, or ability to concentrate?

Yes

Do you have a family history of: (check all that apply)

Early heart disease in a relative younger than 45 years of age

Diabetes

Mental condition

Breast cancer

Other cancer (please name below)

Other cancer

Would you be interested in educational/screening programs on: (check all that apply)

Other program:

Name (confidential)

Age

Height

Weight

Gender

Your Company/Employer

Department/Area

Work Telephone

REMINDER: Only Aiken Regional Medical Centers staff will see your individual information.

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Aiken Regional Medical Centers is owned and operated by a subsidiary of Universal Health Services, Inc.(UHS), a King of Prussia, PA-based company, that is one of the largest healthcare management companies in the nation.

Aiken Regional Medical Centers
302 University Parkway
Aiken, SC 29801
803-641-5000

Note:The information on this Web site is provided as general health guidelines and may not be applicable to your particular health condition. Your individual health status and any required medical treatments can only be properly addressed by a professional healthcare provider of your choice. Remember: There is no adequate substitution for a personal consultation with your physician. Neither Aiken Regional Medical Centers, or any of their affiliates, nor any contributors shall have any liability for the content or any errors or omissions in the information provided by this Web site.

The information, content and artwork provided by this Web site is intended for non-commercial use by the reader. The reader is permitted to make one copy of the information displayed for his/her own non-commercial use. The making of additional copies is prohibited.

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Health Risk Factors Assessment

800-322-8322

Patients and Visitors

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Careers

Hospital Services

Patients & Visitors

Community Outreach

Careers