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Brownsburg Fire Fit For Duty 2021

Health Risk Assessment

Information gathered in the survey process is kept in a confidential manner that abides by all privacy and security regulations and provisions.
1. Demographics *This question is required.
2. Which of the following best represents your racial or ethnic heritage? *This question is required.
3. What is your employment statues?  *This question is required.
4. How long have you been at your current employer? *This question is required.
5. How long has it been since your last routine, physical exam? *This question is required.
6.  If you are 50 years old or older, have you had a colonoscopy (screening test for colon cancer) in the past 10 years? *This question is required.
7. If you are female and over the age of 40, have you had a mammogram in the last 24 months? *This question is required.
8. Please check below any conditions that you have been told by your provider that you have.  *This question is required.
9. Please check below any medications that you are currently taking for your conditions. *This question is required.
10.  Please check below any conditions that you have taken courses or classes to learn how to manage your condition *This question is required.
11. Have multiple family members on the same side of the family had cancer? *This question is required.
12. The following family members are known to have heart disease (select all that apply)
  *This question is required.
13. Have you/your family members been diagnosed with more than one cancer? *This question is required.
14. Are there any breast cancers under the age of 50 or colon/uterine cancers under the age of 64 in your family? *This question is required.
15. Have you or any of your family members been diagnosed with any rare cancers (ovarian and male breast cancer)? *This question is required.
16.  Do you have trouble paying for your medications? *This question is required.
17. Do you feel tired, fatigued or sleepy during the daytime? *This question is required.
18. Do you snore loudly (louder than talking or loud enough to be heard through closed doors)

  *This question is required.
19. Has anyone observed you stop breathing during your sleep?
 
  *This question is required.
20. On average, how many hours of sleep do you get in a 24-hour period?
21. How many vegetables do you eat in a normal day?

  *This question is required.
22. How many fruits do you eat in a normal day?

 
23. Over the past 2 weeks, how often have you drank sugar-sweetened beverages (regular coke, sweet tea, sweetened coffee, sports drinks, etc.)? *This question is required.
24. How many days per week on average do you engage in 30 minutes or more of physical activities outside of your daily work/routine?

  *This question is required.
25. Do you use tobacco products (smoke, chewing, vaping)?

  *This question is required.
26.  Have you routinely used tobacco products in the past?
  *This question is required.
27.  Do you drink alcoholic beverages (beer, wine, liquor)?

  *This question is required.
28. On those days, how many drinks (12oz beer, 5oz wine, 1.5 oz. liquor) on average do you drink?
  *This question is required.
29. Do you use drugs that are not prescribed to you?
  *This question is required.
30.  Do you have ongoing pain that is not controlled with over-the-counter medications?
  *This question is required.
31.  I am up to date with my vaccines.
  *This question is required.
32.  In general, would you say your health is *This question is required.
33. Over the past 2 weeks, how often have you felt nervous, anxious or on edge?
  *This question is required.
34. Over the past, 2 weeks how often have you felt down, depressed or hopeless?
35.  Over the past 2 weeks, how often have you experienced little interest or pleasure in doing things?
  *This question is required.
36.  Does a partner or anyone at home hit, hurt, or verbally threaten you or family members?
  *This question is required.
37.  How often have you moved homes in the last 5 years?
  *This question is required.
38.  How many family and/or friends can you share your feelings with confidence?
  *This question is required.
39. Please identify what topics of wellness interest you the most? 
  *This question is required.
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