Health Risk Assessment

For FEHBP Puerto Rico members ONLY:

Use this form to complete your Health Risk Assessment (HRA) as requested. The form should be completed and signed in all parts.

Required Required

Demographic Data

Number on your Humana medical plan card

MM/DD/YYYY

Required Gender

Health & Wellness Questionnaire

This questionnaire is intended to help us develop a health and wellness program of quality and excellence in the workplace. Select the assertion that corresponds:

Required 1. Mark the highest grade or level of school completed:

Required 2. Are you a member of Humana?

Required 3. In general, how do you consider your current health status?

Required 4. Compared to last year, how would you describe your current health status?

Required 5. Do you smoke?

6. Do you plan on quitting?

7. When would you be willing to quit?

Required 8. Would you like to make changes in your eating habits?

9. When you be willing to start making changes in your eating habits?

Required 10. Do you practice some kind of physical activity such as walking, running, cycling, swimming, playing basketball, doing spinning, aerobics, among others; for 150 minutes a week (this is equivalent to 2½ hours per week)?

11. Do you plan on starting a physical activity?

12. When would you be willing to start a physical activity?

Required 13. When was the last time you had a complete physical exam? (Including laboratory tests and routine examinations)

Required 14. When was the last time you performed any of the following tests: sigmoidoscopy or colonoscopy?

If your biological sex is female, please answer questions #15 through #18, then proceed to question #22. If your biological sex is male, proceed to question #19.

How long ago was your last preventive examination? Please check all that apply.

15. Mammogram

16. Pap Smear Test

17. Do you perform a breast self-exam?

18. Are you pregnant?

How long ago was your last preventive examination? Please check all that apply.

19. Prostate exam by the doctor

20. PSA Blood Test

21. Do you perform the testicular self-exam?

Check the following list of diseases and conditions and identify which of these you have been diagnosed by your doctor and indicate whether you use any mediccation to treat that condition.

Condition or Disease

Have you been diagnosed?

Do you use medication?

22. Arthritis

23. Athsma

24. Cancer

25. High Cholesterol (over 200mg)

26. Depression

27. Diabetes

28. Heart Diseases

29. Chronic Obstructed Pulmonary Disease (COPD)

30. Kidney Failure

31. Obesity

32. Hypertension

33. Thyroid

Have you been diagnosed?

22. Arthritis

23. Athsma

24. Cancer

25. High Cholesterol (over 200mg)

26. Depression

27. Diabetes

28. Heart Diseases

29. Chronic Obstructed Pulmonary Disease (COPD)

30. Kidney Failure

31. Obesity

32. Hypertension

33. Thyroid

Do you use medication?

22. Arthritis

23. Athsma

24. Cancer

25. High Cholesterol (over 200mg)

26. Depression

27. Diabetes

28. Heart Diseases

29. Chronic Obstructed Pulmonary Disease (COPD)

30. Kidney Failure

31. Obesity

32. Hypertension

33. Thyroid

Required 34. Would you like to be contacted by phone by a nurse to provide educational support related to the management of your disease or condition?

Use a check mark (✔) to identify your top five (5) topics of interest: