Home Health Assessment

Welcome to the ParkwayHealth Health Assessment.

This assessment is only for adults (age 20 or above).

All the information will be confidential and will not be recorded. All these questions and reports will give you a general indication for your health.

Please consult with your doctor for an accurate health assessment.

1. You measurements for BMI (Body Mass Index)
Unit Height Weight
Metric   cm kg
Imperial   feet   inches pounds
2. Your Personal and family medical history (Click on all that apply)
History Yes No Don’t know
Diabetes
Heart Disease
Thyroid
Obesity
High Blood Pressure
3. Do you use tobacco in any form? Never used tobacco
Used to smoke tobacco but have quit
Still use tobacco
4. During a typical week, how many days do you engage in physical activity? None
1 or 2 days
3 or more days
5. How often each week do you feel you are under stress? Never or almost never
Sometimes
Often or very often
6. During a typical week, how many days do you eat breakfast?
Don't count coffee alone as having breakfast.		 None
1 to 2 days
3 to 4 days
5 days or more
7. On a typical day, how many servings of vegetables and fruits do you eat?
Don't count potatoes or french fries.		 None
1 to 2 servings
3 to 4 servings
5 or more servings
8. On a typical day, how many alcoholic drinks, including beer and wine, do you drink?
1 drink = 1 can of beer, 1 glass of wine, or 1 ounce of liquor.		 None
1 or 2
3 or more
 

Health Assessment

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