WCA Hospital

SECTION A:
Non-Controllable Risk Factors

1. Indicate the number of members of your direct family who have died or been diagnosed with Coronary Heart Disease before the age of 60.
     None
     One Person
     More than one
   
   
2. Indicate the number of members of your direct family who have died or been diagnosed with Coronary Heart Disease after the age of 60.
     None
     One Person
     More than one
   
   
3. Indicate the number of members of your direct family who have been diagnosed with Diabetes.
     None
     One Person
     More than one
   
   
4. Indicate the number of members of your direct family who have died or been diagnosed with Strokes or Cerebral Vascular Disease.
     None
     One Person
     More than one
   
   
5. Have you ever been diagnosed with any type of cancer?
     Yes
     No
   
   
6. Have you ever been diagnosed with any form of heart disease?
     Yes
     No
   
   

SECTION B:
Personal Health History and Habits

1. If you are over the age of 40, do you have an annual colon/rectal screening?
     Yes
     No
     Not Applicable
   
   
2. If you are a female over the age of 18, do you have an annual PAP smear?
     Yes
     No
     Not Applicable
   
   
3. If you are a female over the age of 35, have you had a mammogram within the past 2 years?
     Yes
     No
     Not Applicable
   
   
4. If you are a male over the age of 40, have you had a prostate screening within the past 2 years?
     Yes
     No
     Not Applicable
   
   
5. How often do you see your physician for routine check-ups or health screenings?
     On an annual basis
     At least every 2 years
     Not within the past 5 years
     Never
   
   
6. Indicate if you have any of the following cancer signs.
     Change in bowel or bladder habits
     Chronic indigestion or difficulty in swallowing
     Thickening or lump in breast or elsewhere
     Unusual bleeding or discharge, a sore that doesn't heal
     Change in feckle or mole
     Persistent cough or sore throat
     Unexplained weight loss
     None
   
   

SECTION C:
Alcohol/Caffeine/Tobacco Consumption

1. How often do you consume alcohol?
     Never drink
     2 days or less per week
     3 days per week
     4 days or more per week
   
   
2. On the days that you drink, on the average how many drinks do you have?
     Never drink
     1 to 2 drinks
     3 to 4 drinks
     5 or more drinks
   
   
3. How often do you consume caffeine in your diet including coffee, tea, cola or chocolate?
     Never
     Occasionally, but not every day
     1 to 3 servings daily
     3 to 5 servings daily
     More than 5 servings daily
   
   
4. Indicate which of the following best represents your current smoking status.
   NOTE: Check all that apply.
     Have never smoked
     Quit smoking less than 5 years ago
     Quit smoking more than 5 years ago
     Smoke pipe or cigar
     Smoke less than 1 pack of cigarettes per day
     Smoke more than 1 pack of cigarettes per day
   
   
5. Do you use smokeless tobacco?
     Yes
     No
   
   

SECTION D:
Exercise Program

1. On the average, how many days per week do you exercise?
     3 or more days per week
     Less than 3 days per week
     No regular exercise program
   
   
2. Do you perform stretching prior to exercise?
     Always
     Sometimes
     Never
     Currently not exercising
   
   
3. Do you warm-up and cool-down after exercising?
     Always
     Sometimes
     Never
     Currently not exercising
   
   

SECTION E:
Nutrition Habits

1. On the average, how many meals do you consume per day?
     3 meals with "healthy" snacks
     3 meals
     2 meals or less
     No regular eating pattern
   
   
2. On the average, indicate the type and amount of grain products you normally consume per day.
   NOTE: A serving is 1 slice bread, 1/3 cup beans/peas, 1/3 cup oatmeal, rice or other grain products.
   Refined grain examples: White bread, rolls and processed flour
     Whole grains, at least 6 to 11 servings per day
     Whole grains, 6 or fewer servings per day
     Refined grains, at least 6 to 11 servings per day
     Refined grains, 6 or fewer servings per day
     Rarely consume grain products
   
   
3. On the average, how many servings of vegetables do you consume per day?
   NOTE: A serving is approximately 1 cup raw or 1/2 cup cooked.
     At least 3 to 5 servings per day
     Less than 3 servings per day
     Rarely consume vegetables
   
   
4. On the average, how many servings of fruit do you consume per day?
   NOTE: A serving is approximately 1 piece of fruit.
     At least 2 to 4 servings per day
     Less than 2 servings per day
     Rarely consume fruit
   
   
5. On the average, how many servings of dairy products do you consume per day?
   NOTE: A serving is approximately 1 cup milk or 1 oz. cheese.
     At least 2 servings per day
     Less than 2 servings per day
     Rarely consume dairy products
   
   
6. Indicate the type of dairy products you consume.
     Nonfat selections only
     Both low fat and nonfat about the same
     Low fat only
     Usually high fat selections
     Do not consume dairy products
   
   
7. Indicate the type of meat you consume.
     Do not consume meat or meat products
     Consume less than 6 oz. of poultry or fish per day
     Consume more than 6 oz. of poultry or fish per day
     Consume less than 6 oz. of red meat per day
     Consume more than 6 oz. of red meat per day
   
   
8. Indicate the type and number of servings of fat, dressings and spreads you consume each day.
   High fat examples: Butter, lard, margarine
   Low fat examples: Nonfat or Low fat salad dressing/mayonnaise/cheese
     Use low fat selections sparingly (less than 3 per day)
     Use low fat selections frequently (more than 3 per day)
     Use both low and high fat about the same sparingly (3 or less)
     Use high fat selections sparingly (less than 3 per day)
     Use high fat selections frequently (more than 3 per day)
   
   
9. On the average, how many glasses of water do you consume per day?
   NOTE: A serving is one 8-oz. glass of water only; do not include coffee, soda or other beverages.
     At least 8 glasses per day
     About 4 to 8 glasses per day
     Less than 4 glasses per day
     Rarely consume water
   
   
10. On the average, how many times per day do you eat convenience foods or forms of fast food?
      Never
      Less than 1 time per day
      More than 1 time per day
    
    

SECTION F:
Personal Health

1. Do you have an annual check-up with your Dentist?
     Yes
     No
   
   
2. Do you have any abnormal bleeding in your gums or around your teeth?
     Yes
     No
   
   
3. How often do you see an eye specialist?
     Once per year
     Once every two years
     Not within the last 2 years
     No regular exams
   
   
4. Do you live or work in an environment which you consider to expose you to pollution, either air, water or from your food?
     Yes
     No
   
   
5. Do you have at least one working smoke detector for each floor of your home or apartment, which you check on a monthly basis?
     Yes
     No
   
   
6. How often do you use your seatbelt when either operating a motor vehicle or riding as a passenger?
     Always
     Sometimes
     Never
   
   
7. How many miles per month do you drive an automobile or ride as a passenger?
     Less than 1000
     Between 1001 and 1499
     More than 1500
   
   
8. If you own an automobile, do you have regular maintenance performed such as checking the tires, oil, etc.?
     Yes
     No
     Not applicable
   
   
9. Do you have a working fire extinguisher in your home?
     Yes
     No
   
   

SECTION H:
Osteoporosis

1. Have you ever been diagnosed with or indicated that you were at risk for Osteoporosis?
     Yes
     No
     Not applicable