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975 East Third Street
Chattanooga, TN 37403
423-778-7000
Children's Hospital at Erlanger Erlanger Baroness Campus Erlanger Bledsoe Campus Erlanger East Campus Erlanger North Campus UT Erlanger Physicians Group





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Hamilton County Health Risk Assessment

Please fill out the information as accurately as possible.

Have you experienced any of the following? 














 
How often do you eat foods such as eggs, red meat, fried foods, whole milk products, gravies, or creamy salad  




 
How often do you eat whole grain foods such as bread, cereal, pasta, rice, and bran products? 




 
How often do you eat fruits and vegetables? 




 
How often do you drink beverages containing caffeine?  




 
How often do you snack on cakes, candy, etc.? 




 
Indicate your tobacco usage below: (mark all that apply) 




 
I smoke ### cigarettes/cigars/pipes per day 
 
Stopped smoking cigarettes ### years ago 
 
When out in the sun for one hour or more, do you: (mark all that apply) 



 
On the average, how often do you drink alcoholic beverages? ^  



 
Has a close friend or family member ever told you that you may have a drinking problem? 
 
Are you regularly exposed to nickel, chromate, vinyl chloride, asbestos, coal dust, or cotton dust?  
 
How well do the following traits describe you? Are you Competitive? 


 
How well do the following traits describe you? Are you bossy? 


 
How well do the following traits describe you? Are you pressed for time? 


 
How well do the following traits describe you? Are you easily angered? 


 
How well do the following traits describe you? Are you always in a hurry? 


 
Have you noticed that recently you seem to be: (Mark all that apply) 









 
How would you describe your normal day's activities? 



 
How often do you perform regular physical exercise  



 
How often do you participate in strengthening/toning exercise such as weight lifting, calisthenics, etc.?  



 
When was your last Proctosigmoidoscopy Test? - A proctosigmoidoscopy is the visual examination of the rectum and  



 
Women Only: 18a. Do you perform regular Breast Self-Examinations? 
 
Women Only: 18b. Please mark when you last had a Mammogram (Breast X-ray) performed by a physician:  



 
Women Only: 18c. Please mark when you last had a breast exam performed by a physician: 



 
Women Only: 18d. Please mark when you last had a pelvic exam by a physician: 



 
Women Only: 18e. Please mark when you last had a pap test performed by a physician:  



 
Men Only: 19a. Please mark when you last had a testicular examination performed by a physician:  



 
Men Only: 19b. Please mark when you last had a prostate examination performed by a physician:  



 
When did you last have a thorough physicial examination performed by a physician? 




 
Do you have a physician with whom you can share the results of this test? 
 
If Yes, Physician's Name 
 
How many days of work have you missed in the last 12 months due to personal illness? 
 
How much did your health problems affect your productivity at work over the last 30 days? 



 
Has your job performance over the last 12 months changed compared to your perfomrance during the prior year?  


 
Within the next six months, do you plan to make any changes that will improve your health?  




 
In the next 6 months, would you attend a program that is designed to help you enhance your overall health?  
 
Would you like a health care specialist to contact you to tell you about services to enhance your health? (If you  
 
Please indicate from which areas you would like more information 







 
Have either of your parents or any of your brother or sisters (excluding relatives by marriage or adoption) every had any of the following cardiovascular problems at an early age (that is under age 55 for males and under age 65 for females)? 







 
Have either of your parents and/or any of your brothers or sisters (excluding relatives by marriage or adoption) ever had cancer? 
 
If yes, what type of cancer? 
If yes, which relative? 
 
Have either of your parents and/or any of your brothers or sisters (excluding relatives by marriage or adoption) ever had diabetes? 
If yes, which relative? 
 
Name 
Address: 
City 
State 
Zip Code 
Telephone (Home) 
Telephone (Work) 
Cell phone 
Sex 
Date of Birth 
Primary Care Physician 
Physician's Phone Number