PRIME DX Health Risk Assessment Questionnaire Group Date Completed Member Information Member Name Member SSN Member Email Member DOB Member Phone Diagnoses and Medications 1) Have you been diagnosed with any of the following: ☐Cerebrovascular Disease ☐Asthma (Stroke) ☐Cancer ☐Chronic Obstructive ☐Diabetes Pulmonary Disease ☐Hypertension ☐Coronary Artery Disease 2) Are you taking Medications for any of the following: ☐Cerebrovascular Disease ☐Asthma (Stroke) ☐Cancer ☐Chronic Obstructive ☐Diabetes Pulmonary Disease ☐Hypertension ☐Coronary Artery Disease ☐Kidney Disease ☐Liver Disease ☐Thyroid Disease ☐None of the Above ☐Kidney Disease ☐Liver Disease ☐Thyroid Disease ☐None of the Above 3) Please list any other medications you are taking. Hospital, ER, and Doctor 4) Have you been admitted to the Hospital in the past year? ☐Yes ☐No 5) How many times were you admitted to the Hospital in the last year? 6) Have you been to the emergency room 2 or more times in the past year? ☐Yes ☐No A. Please list the number of ER visits in the past year? 7) Do you have Difficulty taking your prescribed medications? ☐Yes ☐No A. If Yes, Why? 8) Do you have significant health problems that affect your daily activities and result in frequent doctor’s visits: ☐Yes ☐No 9) When was your last Annual Check Up with a doctor? PRIME DX Health Risk Assessment Questionnaire 10) Do you have a regular doctor? ☐Yes ☐No If Yes, Who: 11) What is your weight? 12) What is your height? Smoking, Diet, & Exercise 13) Do you Smoke? ☐Yes ☐No If Yes, How many per day? 14) Do you plan to quit smoking in the next 6 months? ☐Yes ☐No 15) Please choose your attitude towards your eating habits: 16) Do you Exercise? ☐Yes ☐No 17) Please choose your attitude towards physical exercise: 18) Please rate your following based on what you have experienced in the last 6 months: A. Difficulty coping with Normal Daily Activities: B. Worry or Gloom C. Feeling energized or motivated Female Only Section 19) If over age 21: Have you Completed your Annual Pap Smear & Cervical Cancer Screening? ☐Yes ☐No i. When? 20) If over age 40: Have you completed your annual Mammogram? ☐Yes ☐No i. When? Male or Female over age 50 21) If over age 50: Have you completed your Colonoscopy, sigmoidoscopy, or Stool Occult Blood test for Colorectal Screening: ☐Yes ☐No When?