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

Demographic Data

First Name

Last Name

Mother's maiden name

Contract number

Number on your Humana medical plan card

Date of Birth MM/DD/YYYY

Gender

Female
Male

Phone Number

E-mail

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:

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

Elementary (1st to 6th grade)
Junior High (7th to 9th grade)
High School (10th to 12th grade)
College (Certiﬁcate, Associate Degree, Bachelor’s Degree)
Graduate Level (Master, Doctorate, others)

2. Are you a member of Humana?

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

Excellent
Good
Fair
Poor

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

Much better than a year ago
Somewhat better than a year ago
Same as a year ago
Worse than a year ago

5. Do you smoke?

Yes
No (If you answered no, skip to question #8)

6. Do you plan on quitting?

Yes
No (If you answered no, skip to question #8)

7. When would you be willing to quit?

In the next month
In the next 6 months
In the next 12 months

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

Yes
No (If you answered no, skip to question #10)

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

In the next month
In the next 6 months
In the next 12 months

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)?

Yes
No (If you answered no, skip to question #13)

11. Do you plan on starting a physical activity?

Yes
No (If you answered no, skip to question #13)

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

In the next month
In the next 6 months
In the next 12 months

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

In the last 12 months
More than a year ago
I don’t remember
Never

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

In the last 12 months
In the last 5 years
In the last 10 years
I don’t remember
Never

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

Less than 12 months
More than 1 year
More than two years
Do not remember
Never

16. Pap Smear Test

Less than 12 months
More than 1 year
More than two years
Do not remember
Never

17. Do you perform a breast self-exam?

Once a month
Once every two months
Once a year
Never

18. Are you pregnant?

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

19. Prostate exam by the doctor

Less than 12 months
More than 1 year
More than two years
Do not remember
Never

20. PSA Blood Test

Less than 12 months
More than 1 year
More than two years
Do not remember
Never

21. Do you perform the testicular self-exam?

Once a month
Once every two months
Once every six months
Never

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.

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?

Health Risk Assessment

For FEHBP Puerto Rico members ONLY:

Errors occurred... The following items require your attention

Demographic Data

Consent Form and Liability Release

Health & Wellness Questionnaire