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PSMAS HRA SURVEY

Wellness HRA Survey

Fill in your details to become part of PSMAS' Health Risk Assessment (HRA) survey. Your information will not be used for an other use and is confidentially secured.

Demographics

Date of Birth

National ID:

MEDICAL HISTORY

Do you suffer from any of the following. If yes, select the appropriate condition(s):

Do you suffer from back pain?: *

Yes

If your answer is yes to back pains, choose how often?:

Have you ever been admitted to a hospital in the last 5 years?:*

Yes

If yes, state the reasons for admission:

Average sleeping duration:

Beneficiaries

Beneficiary Name

If on the following chronic disease(s) (Diabetes, Hypertension, Cancer, Chronic back, Stress and mental health problems), kindly list medicine

FAMILY AND SOCIAL HISTORY

Do you smoke?:*

Yes

If yes, how many years?:

If yes, average cigarettes:

Do you drink alcohol?:

Yes

If yes to, how do you consider yourself as a drinker?:

Do you do any physical exercises?:

Yes

If yes, how frequent?:

Do you consider yourself as someone who eats a healthy balanced diet?: *

I never do this

Sometimes l do

I always do this

Any family member, first cousin diagnosed of cancer?:

Yes

If yes, what type of cancer?:

Has any family member been diagnosed with any of the following chronic disease? Select the appropriate diseases?:

HEALTH AND LIFESTYLE MANAGEMENT

Systolic Blood Pressure:

Diasystolic Blood Pressure:

Pulse/BPM:

Cholestrol/mmols:

Height (cm):

Weight (kg):

Waist circumference (cm):

Hip circumference (cm):

Body fat (%):

Blood glucose/mmols:

BEHAVIOURAL-READINESS TO CHANGE

How would you rate your readiness to change should you be advised or initiated in any program meant to improve your health related behaviour? Choose appropriate answer:

Not ready

Not sure

Ready

Very ready