About Yourself...
Group:*	Select One... 2016 Hillsboro Area Hospital 2017 Hillsboro Area Hospital 2018 Hillsboro Area Hospital 2019 Hillsboro Area Hospital 2020 Hillsboro Area Hosptial 2021 Hillsboro Area Hospital 2022 Hillsboro Area Hospital 2023 Hillsboro Area Hospital AIMM Demo AIMM Demo Healthy Metrics Version All Care Health Center Aradius Group B&I Contractors Belfint Blossman Companies Chicago Lumber 2018 Demonstration Purposes Hoyt's Truck Center Jani King Gulf Coast Region New Format - Demo Only SavATree Sawgrass Ford Stephen’s AutoMall Centre Tampa Truck
First Name:*
Last Name:*
Insured's Name:*
Insured's Employer:*
Insured's Card ID:
Home Address:
Home Phone Number:
Contact Phone Number* (9am to 5pm EST):
ID/Social Security Number:* Unique ID:*	format: ######### format: AAAAAA###AAAA
Date of Birth:*	format: mm/dd/yyyy
Height:*	feet inch(es)
Weight:*	pounds
Gender:*	Male  Female
Primary Language:*	English  Spanish  Other:
Race:*	African American  Asian  Hispanic/Latino  Native American  Pacific Islander  White  Other

Current Health Status...* an answer is required for each question
I would rate my current health status as:	Excellent  Good  Average  Poor  Extremely Poor
I currently take ___ medications per day:	None  1-3  3-5  More than 5
I was treated in the Emergency Room ___ times this past year:	None  1  2  3  4 or more
I was hospitalized ___ times this past year:	None  1  2  3  4 or more
I currently have the following health problems:	Migraines or Recurrent Headaches  Frequent Dizziness or Blurred Vision  Chronic Sinus Problems or Infections  Recurrent or Frequent Colds or Flu  Severe Allergies  Recent Stroke or TIA (Transient Ischemic Attack)  Frequent Ear Infections and/or untreated hearing loss  Frequent or Severe Dental Problems  Frequent Sore Throats or Throat Infections  Asthma  COPD, Emphysema, Severe or Frequent bronchitis  Recent Heart Attack, Bypass Surgery, Cardiac Catheterization  Hypertension or High Blood Pressure  Elevated Cholesterol or Triglycerides  Irregular Heart Beat, Arrhythmia, Atrial Fibrillation, SVT  Peptic Ulcers, Severe or Recurrent Heartburn  Frequent Abdominal Pain or Vomiting  Recurrent Constipation and/or Diarrhea  Renal Failure, Dialysis  Trouble Urinating  Menstruation Problems  Sexual Dysfunction or Reproductive difficulties  Frequent Swelling of legs or feet  Blood Clots in legs, DVT  Recurrent or Frequent Broken Bones  Osteoporosis  Chronic Back Pain  Loss of Sensation in Arms or Legs  Chronic Pain in location other than back  Cancer or Leukemia  Diabetes  Anxiety  Stress  Depression  Other:  None of the above

About your lifestyle...* an answer is required for each question
Are you currently pregnant?	Not Applicable  Yes  No
How many servings of fruit and vegetables do you eat per day?	None  1-4  At least 5
How many servings of whole grain do you eat per day?	None  1 or 2  3 or more
How many servings of dairy (milk, cheese, etc.) do you consume per day?	None  1 or 2  3 or more
Do you eat green leafy vegetables (kale, spinach, lettuce, etc…) on most days?	Yes  No
How many servings of fish/seafood do you eat per week?	None  1  2 or more
How many times per day do you eat butter, lard, red meat, cheese, whole milk?	None  1  2 or more
Do you eat stick margarine, vegetable shortening, store bought baked goods (cookies, cakes, pies), or deep fried fast foods on most days?	Never  Less than 3 days per week  4 or more days per week
Do you eat oil based salad dressing or use liquid vegetable oil for cooking on most days?	Yes  No
How many servings of refined starch (white bread, white rice, white pasta, potatoes, low fiber cereal like puffed rice or corn flakes) do you eat per day?	None  1  2  3 or more
What is your normal daily consumption of alcohol?	None  1  2  3  4 or more
Do you utilize any street drugs, or prescription drugs not prescribed specifically for you?	Yes  No
Do you smoke?	Yes  No  Used to, but I have quit
Are you routinely or frequently exposed to other people’s smoke from cigarettes or cigars?	Yes  No
Do you use chewing tobacco?	Yes  No  Used to, but I have quit
How many days per week do you walk at least 30 minutes (or do at least 30 minutes of cardiovascular exercise)?	None  1-3  4-6  7
Have you recently been experiencing any of the following (check all that apply)?	Feelings of sadness, anxiety or hopelessness every day for 2 or more weeks  Lack of interest or pleasure in usual activities, hobbies, or pastimes  A sudden increase or decrease in appetite  Trouble sleeping for 2 or more weeks  Excessive sleepiness  Thoughts of death or suicide  Low energy every day for 2 or more weeks  Restlessness  Irritability  Feelings of worthlessness  Change in work performance  None of the above
Does your spouse or significant other (check all that apply):	Hurt you physically when he/she gets angry  Prevent you from seeing your friends or family  Threaten you or yell at you  Make you feels worthless or powerless  Intimidate, berate, or harass you verbally  None of the above
Are you the primary caregiver for a family member, friend, or do you provide care for someone as your occupation?	Yes  No  I used to be
What is your blood pressure?	Unknown Systolic (top number)  <90  90 - 135  135 - 150  > 150 Diastolic (bottom number)  <50  50 - 90  > 90
What is your total cholesterol?	Over 300  200 to 300  Less than 200  Unknown
What is your HDL?	Over 35  29 to 35  Less than 29  Unknown
What is your LDL?	Over 130  Under 130  Unknown
What is your fasting blood sugar?	Over 250  150 – 250  115 – 150  70 – 115  Under 70  Unknown
Do you perform breast self-examination?	Not applicable  Yes, at least monthly  Yes, but not on a regular schedule or only occasionally  No
Do you perform testicular self exam?	Not applicable  Yes, at least monthly  Yes, but not on a regular schedule or only occasionally  No
Have you recently noticed any of the following (check all that apply):	A lump or thickening in the breast/chest or armpit  Any flattening or indentation of the breast/chest skin  Any puckering, pitting or dimpling of the breast/chest skin  Clear or bloody nipple discharge  A nipple that suddenly becomes retracted or drawn inward  Redness of the breast/chest skin  None of the above
When was your last mammogram?	Not applicable  I am over 50, or have found a lump on breast self exam, or have a family history of breast cancer, but have never had a mammogram  I am under 50, have never found a lump on breast self exam, and have no family history of breast cancer so have never had a mammogram  My last mammogram was within the past 1 year  My last mammogram was within the past 2 years  My last mammogram was more than 2 years ago
When was your last Pap test?	Not applicable  Prior to my hysterectomy  More than 3 years ago  Between 1 and 3 years ago  Less than 1 year ago  I have never had a Pap Test
When was your last prostate exam?	Not applicable  Within the past year  I am under 50 and have had an exam within the past 5 years  I am over 50 and have had an exam between 1 and 5 years ago  Over 5 years ago  I have never had a prostate exam
When was your last colorectal cancer screening?	I am under 50 years old and have never had a sigmoidoscopy  I am over 50 years old and have had a sigmoidoscopy within the last 7 years  I am over 50 years old and had a sigmoidoscopy more than 7 years ago  I am over 50 years old and have never had a sigmoidoscopy
When was your last dental exam?	Never  More than 5 years ago  Between 1 and 5 years ago  In the past 1 year
When was your last flu shot?	I never get flu shots because I am allergic  My doctor has advised me to not take flu shots  I am under 50 and do not routinely get flu shots  I am over 50 and do not routinely get flu shots  I get a flu shot annually
Have you had any recent (within the last 6 months) changes in bladder or bowel habits?	No  Yes, but my doctor said it was normal  Yes, and I have not yet discussed it with a doctor
Have you noticed a lump or thickening in the breast or elsewhere?	No  Yes, but my doctor said it was normal  Yes, and I have not yet discussed it with a doctor
Have you had any unusual bleeding or discharge?	No  Yes, but my doctor said it was normal  Yes, and I have not yet discussed it with a doctor
Do you have any slow or non-healing sores?	No  Yes, but my doctor said it was normal  Yes, and I have not yet discussed it with a doctor
Have you had any obvious changes to size, shape, or color of a wart or mole?	No  Yes, but my doctor said it was normal  Yes, and I have not yet discussed it with a doctor
Have you recently had a nagging cough or hoarseness?	No  Yes, but my doctor said it was normal  Yes, and I have not yet discussed it with a doctor
If given the opportunity to work with a nurse to alter your risk creating lifestyle, behavior, or diet practices I would...	Be an active participant in anything the RN had to offer as long as it was inexpensive  Be an active participant in anything the RN had to offer as long as it was free  Listen to what the RN has to say then make my own adjustments  Prefer to have information by mail or e-mail only, and not talk with a RN  Not be willing to address these issues further

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