WELCOME TO COMMUNITY!
We are happy to have you as our Member. Community is dedicated to providing you great health care. We also want to help you take charge of your own health! Please take our Health Risk Assessment. We will keep your answers private and only use them to improve the care that we give you. Fill out the survey and submit. We will review it and contact you if we see any potential issues. In addition, share your results with your doctor.
Thank you
for helping Community serve you better!
*Member ID:
Invalid ID
*First Name:
*Last Name:
*Phone Number:
*Date of Birth:
*Birth day:
*Birth year:
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1880
*Gender:
Gender
Male
Female
*Email Address:
*Weight (in pounds):
*Height: Feet:
Inches:
My Health
*When was your last checkup?
Month:
select
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12
Year:
select
2019
2018
2017
2016
2015
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2012
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2010
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2003
Don't remember/Never had
*Last Colonoscopy? (If over 50+ years)?
Month:
select
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12
Year:
select
2019
2018
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Don't remember/Never had
*When was your last tetanus shot?
Month:
select
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Year:
select
2019
2018
2017
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2008
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2003
Don't remember/Never had
Women Only
*About how long has it been since your last mammogram(breast x-ray)?
Number of Years:
Don't remember/Never had
*When did you have your last pap smear?
Month:
select
1
2
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10
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12
Year:
select
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
Don't remember/Never had
*Has a health care provider ever said you have had any of the following?
(Please check any that apply.)
Cancer
Diabetes
Heart attack
Heart disease
High blood pressure
High cholesterol
Stroke
Asthma
COPD
*Which describes your blood pressure?
(Please check one.)
Blood pressure
High
Normal
Low
Don't know
Blood Pressure Reading:
Blood Pressure High number
Blood Pressure Low number
/
*Which describes your cholesterol?
Cholesterol
High
Normal
Low
Don't know
*Describe your tobacco use:
Tobacco
Never used tobacco
Used to smoke or chew
Still smoke or chew
Nutrition
Would you like information about healthy diets?
Healthy diet
Yes
No
Fitness
*How often do you exercise?
Exercise
Every day
3-5 times per week
Once a week
1-2 times per week
Never/almost never
*For how long?
Exercise length
10-15 min
15-30 min
30-60 min
More than 60 min
I don't exercise
Wellbeing
*Considering your age, how would you describe your overall health?
Overall health
Excellent
Good
Fair
Poor
*In general, how satisfied are you with your life?
Life satisfaction
Satisfied
Not satisfied
*Have you felt depressed during the past month?
Depression
Yes
No