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: month 1 2 3 4 5 6 7 8 9 10 11 12 /  day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 /  year 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 1899 1898 1897 1896 1895 1894 1893 1892 1891 1890 1889 1888 1887 1886 1885 1884 1883 1882 1881 1880 1879                          *Gender:  Gender Male Female *Email Address:  *Weight (in pounds):      *Height:   Feet:        Inches:              My Health *When was your last checkup? Month: select 1 2 3 4 5 6 7 8 9 10 11 12 Year: select 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 Don't remember/Never had *Last Colonoscopy? (If over 50+ years)? Month: select 1 2 3 4 5 6 7 8 9 10 11 12 Year: select 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 Don't remember/Never had *When was your last tetanus shot? Month: select 1 2 3 4 5 6 7 8 9 10 11 12 Year: select 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 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 3 4 5 6 7 8 9 10 11 12 Year: select 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 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 ExcellentGoodFairPoor *In general, how satisfied are you with your life?   Life satisfaction SatisfiedNot satisfied *Have you felt depressed during the past month?   Depression YesNo