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Dear Worksite Wellness Program Participant Please read this cover

VIEWS: 4 PAGES: 8

									FLORIDA DEPARTMENT Of
Ana M. Viamonte Ros, M.D.. M.P.H.
Secretary of Health
Charlie Crist
Governor
Dear Worksite Wellness Program Participant:
Please read this cover letter at least two days before your scheduled
appointment.
Welcome to the Manatee County Health Department's Wellness Program. Your
employer has chosen to provide this important service to increase your awareness of
health risks that may be preventing you from enjoying the healthiest life style possible.
We have attached a brief health history and Health Risk Appraisal questionnaire for you
to complete and bring to your appointment. Skip the questions you do not know
(example: cholesterol level). Completing the information ahead of time greatly
reduces the time away from your work.
On your scheduled appointment date, please plan to be away from your workstation for
approximately 15 minutes. Your supervisor should be notified when you come for your
screening. At the time you are screened we will record your height, weight and blood
pressure, review your paper work and obtain a blood sample. You will be given a time
and date when results will be available. All results are confidential and go only to
the employee.
Please do not eat anything at least 12 hours prior to your appointment time. You may
drink all the water you wish because drinking plenty of water the night before and
the morning of the test helps with obtaining your blood sample. You may take your
routine medications with water. If you are taking medication that must be taken with
food, then you will need to wait to take that medication until after the blood testing is
completed. If fasting is not possible, please telephone us at 748-0747, ext. 1403. Also,
for a more accurate blood test result, it is recommended that you refrain from alcoholic
beverages for 48 hours (2 days) before your test. Please note: Do not participate in
the screening if you faint from needles or having blood drawn.
We look forward to working with you.
THE ADULT HEALTH TEAM
Manatee County Health Department
410 6th Avenue East
Bradenton, FL 34208
(941) 748-0747 ext 1404
Health and Lifestyle Profile Questionnaire
1. Name
2, SS Number
Family Doctor:
3. Address
5. State
6. Zip Code.
4. City.
9. Gender: □ Male □ Female
7. Date of Birth
8. Age
.(H) Ph#
Race
Ph#
(W) New client? Yes or No
10. Height (in)
11. Weight (lb)
12. Hips (in)
13. Waist (in)
14. Body Frame Size; □ Small □ Medium □ Large
To estimate your frame size, measure your wrist by wrapping your thumb and middle finger
around the opposite wrist. Small = fingers overlap V* in. or more. Med. = your fingers touch or
overlap less than 14 in. Large = your fingers do not meet.
15. What is your percent body fat? (leave blank if you don't know)
%
16. What is your blood pressure (mm Hg)? (R)
If you do not know the numbers, check the box that describes your blood pressure.
□ High □ Normal or Low □ Don't Know
/
M
l
17. Are you now taking medicine for high blood pressure?
□ Yes □ No
18. What is your blood cholesterol (mg/dl)?	
If you do not know the number, check the box that describes your blood cholesterol.
□ High □ Normal or Low □ Don't Know
19. What is your HDL (mg/dl)?	
If you do not know the number, check the box that describes your HDL.
□ Low □ Normal or High □ Don't Know
20. What is your LDL (mg/dl)?
21. What is your triglycerides level (mg/dl)?
22. What is your blood glucose level (mg/dl)?
copyright © 1997 E2 Consulting, Dallas, Texas
Cigarette Smoking
23. How would you describe your cigarette smoking habits?
□	Never Smoked (go to 24)
□	Used to Smoke (go to 23B)
□	Still Smoke (go to 23A)
23A. Still Smoke
How many cigarettes a day do you smoke?
23B. Used to Smoke
How many years has it been since you smoked cigarettes fairly regularly? _
What was the average number of cigarettes per day that you smoked in the 2 years
before you quit?	
Cigars and pipes
24. How many cigars do you currently smoke per day?
25. How many pipes of tobacco do you currently smoke per day?
26. How many times per day do you currently use smokeless tobacco?
27. On a typical day how do you usually travel?
□	Walk
□	Bicycle
□	Motorcycle
□	Sub-compact or compact car
□	Mid-size or full-size car
□	Truck or van
□	Bus, subway, or train
□	Mostly stay at home
28. In the next 12 months how many thousands of miles will you travel by each of the following?
	,000 Car, truck, van: (Average is 10,000 per year)
	,000 Motorcycle:
29. What percent of the time do you usually buckle your safety belt when driving or riding?
30. How many times in the last month did you drive or ride when the driver had perhaps too much
alcohol to drink?	
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31. On average, how close to the speed limit do you usually drive?
□	Within 5 mph of limit
□	6-10 mph over limit
□	11-15 mph over limit
□	More than 15 mph over limit
32. Do you have working smoke detectors in your home?
□ Yes □ No
33. Do you have a working fire extinguisher in your home?
□ Yes □ No
34. Does every bathtub and bathroom floor in your home have a nonskid surface or rubber mat?
□ Yes □ No
35. When you lift a heavy object do you bend your knees and keep your back straight?
□ Yes □ No
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it'on|
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36. How many DAILY servings of the following do you usually eat?
Servings
food	
Breads, cereal, rice and pasta
Vegetables	
Serving Size
" 1

1/2 cup
1/2 cup
1/2 cup
1 cup
Fruit
Milk, yogurt, and cheese	
Meat, poultry, dry beans, eggs and nuts
Size of a deck of cards
37. How many 8 oz glasses of water do you usually drink each day?
38. How many times per day do you brush your teeth?	
□ 3+ times □ 2 times □ 1 time □ Less than once
39. Do you floss daily?
□ Yes □ No
40.	How many drinks of alcoholic beverages do you have in a typical week?
	Beers
	Wine
	Wine Coolers
	Liquor
41.	How often do you eat foods high in fat such as fatty meat and fried foods?
□	Daily
□	3-6 times per week
□	1-2 times per week
□	A few times per month
□	Rarely
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42. How do you feel you are currently coping with life in general?
□	Seldom stressed, coping very well
□	Sometimes stressed, coping fairly well
□	Often stressed, trouble coping at times
□	Heavily stressed, often have trouble coping
□	Excessively stressed, unable to cope
43. Have you felt tired, worn out, used up or exhausted during the past month?
□	The majority of the time
□	Less than half of the time
□	Only occasionally
□	Seldom or never
44. How supportive do you feel your family and close friends are?
□	Very supportive
□	Somewhat supportive
□	Not very supportive
45. Check ail of the following stress management techniques that you use:
□	Participate in a hobby
□	Belong to a social group
□	Practice deep relaxation 3x/wk
□	Practice time management skills
46. How often do you do strength building exercises such as setups, pushups or use weight
training equipment?
□	Seldom or never
□	Once a week
□	Twice a week
□	Three or more times per week
47. How often do you do stretching exercises specifically for your lower back and thighs?
□	Seldom or never
□	Once a week
□	Twice a week
□	Three or more times per week
48. Which selection best describes your general ACTIVITY LEVEL for the PREVIOUS MONTH?
"Moderate Activities" include brisk walking, heavy housework, yard work, and recreational
sports.
"Heavy Activities" include running, aerobic dance, heavy moving and competitive sports like
basketball, soccer, etc.
(See next page for selections)
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□
Avoid all exercise and physical activity
Walk for pleasure, routinely use stairs, etc.
Some moderate activity (10 to 60 minutes per week)
More moderate activity (over one hour per week)
Some heavy activity (less than 30 min/week)
Heavy activities totaling 30-60 min/week
Heavy activities totaling 1-3 hours/week
Heavy activities totaling 3+ hours/week
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Women Only (men skip to Preventive Exams)
49. At what age did you have your first menstrual period?
years
50. How old were you when your first child was born (if no children, leave blank)?
.years
51. How many women in your natural family (mother and sisters only) have had breast cancer?	
52. Have you had a hysterectomy?
□ Yes □ No
Preventive Exams
Last Exam
Preventive Exams
Physical Exam
Dental Exam
Digital Rectal Exam
Stool Blood Test
Never <30 days <1
< 2 Years <3 Years <5 years
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Sigmoidoscopy
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Self Skin Exam
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Women
Self Breast Exam
Clinical Breast Exam
Mammography
Pap Smear
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Self Testicular Exam
Prostate-Specific Antigen
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Medical Histo
54. Do you know how AIDS/HIV is prevented?
□ Yes □ No
55. Check below the medical conditions experienced by someone in your immediate family
(parents, grand parents, brothers, or sisters).
□	Heart attack
□	Stroke
□	Cancer
□ Diabetes
□	High blood pressure
□	Alcoholism
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56.	Have you ever been told that you have diabetes?
□	Yes □ No
57.	Have you ever had cancer?
□	Yes □ No
58. Are you at possible risk for HIV?
□ Yes □ No
59. Do you have fair skin?
□ Yes □ No
60. Do you use sun block?
□ Yes □ No
61. How many days in the last year have you been sick enough to miss work?
62. How would you rate your overall health?	
□ Poor	□ Fair	□ Good
□ Excellent
Physical Fitness
For each question below, please mark Yes or No. Physical activity or exercise means walking briskly,
vacuuming, jogging, digging in the garden, climbing stairs or any other physical activity where the exertion
is similar to these.
Regular physical activity or exercise means accumulating 30 minutes or more in the above activities most
days of the week. For example, you could take one 30-minute walk, jog, bike, swim or three 10-minute
walks or 5 minutes of vacuuming, 10 minutes of walking, 10 minutes of digging in the garden, and 5
minutes of climbing stairs.
63.1 am currently physically active?
□	Yes □ No
64.1 intend to become more physically active in the next 6 months?
□	Yes □ No
65.1 currently engage in regular physical activity? 	
□	Yes □ No
66.1 have been physically active regularly for the past 6 months?
□	Yes □ No
67.1 have been physically active regularly in the past for a period of at least 3 months?
□	Yes □ No
Choosing a Low-Fat Diet
68.	Do you currently avoid eating high fat foods?
□	Yes □ No
69.	Do you intend to avoid eating high fat foods in the next six months?
□	Yes □ No
70.	Do you intend to avoid eating high fat foods in the next 30 days?
□	Yes □ No
71.	Have you been avoiding eating high fat foods for than 6 months?
□	Yes □ No
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Could I be infected with HIV? - Six questions to ask yourself
1,	Have I had unprotected sex (without a condom or latex barrier) with anyone other than my
lifelong partner?
a) yes
2,	Has my partner ever had sex with anyone other than me?
a) yes
b) no
c) unsure
c) unsure
b) no
Is my partner "unfaithful"?
b) no
3.
c) unsure
4.
a) yes
Have I ever used any injecting drugs, and shared needles?
a) yes
Have any of my partners ever used injecting drugs?
a) yes
Have I ever had sex with someone who has HIV?
5.
c) unsure
b) no
6.
b) no
c) unsure
a) yes
b) no
c) unsure
If you answered YES or UNSURE to any of the above questions, you may be at risk for HIV. Come
talk to one of our counselors, who can answer your questions and help you decide if HIV testing is
for youl The service is free! The peace of mind is priceless! For more information call: Manatee
County Health Department: 748-0747, ext. 1264, or 1217, or 1387.
How did you hear about us?
o
I give my permission for Manatee County Health Department to obtain appropriate venipuncture (blood)
samples and other health data needed for purposes of the Healthy Advantage for Tomorrow "HAT"
Program. I understand testing for AIDS or drug screening will not be done. My Private Physician may be
notified of abnormal test results. Follow-up on referrals given by MCHD staff members is the responsibility
of the participant who signs this consent.
Date:
Signed:
SS# (for blood work)
Witness:
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