Use this form to complete your Health Risk Assessment (HRA) as requested. The form should be completed and signed in all parts.
Mother's maiden name
Date of Birth
I hereby consent to the Education and Prevention Department of Humana and their representatives to the administration of wellness screening tests:
I understand that the individual results of these screening tests will not be shared with my employer and will be used exclusively by Humana, in compliance with federal and state laws of health information management for their clinical and educational programs.
I understand that:
I release and discharge Humana, its shareholders, ofﬁcers, directors, employees and agents, and the owners/operators of this facility and its parent, subsidiaries, ofﬁcers, directors and employees, from any and all claims or causes of action, on account of injury to me which may result from my participation in this screening (including a failure of the screening to detect any particular health problem). This release shall be binding upon my heirs, assigns, executors, administrators and representatives. I hereby consent to the administration of wellness screening tests.
I have read (or it has been read to me) and agree with all the terms and conditions listed above.
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:
1. Mark the highest grade or level of school completed:
2. Are you a member of Humana?
3. In general, how do you consider your current health status?
4. Compared to last year, how would you describe your current health status?
5. Do you smoke?
6. Do you plan on quitting?
7. When would you be willing to quit?
8. Would you like to make changes in your eating habits?
9. When you be willing to start making changes in your eating habits?
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?
13. When was the last time you had a complete physical exam? (Including laboratory tests and routine examinations)
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.
16. Pap Smear Test
17. Do you perform a breast self-exam?
18. Are you pregnant?
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?
25. High Cholesterol (over 200mg)
28. Heart Diseases
29. Chronic Obstructed Pulmonary Disease (COPD)
30. Kidney Failure
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: