Sample Health Risk Assessment (HRA)
On the answer sheet provided, please circle the number which best identifies your response to each
corresponding statement.
1. Never or Almost Never
2. Occasionally
3. Often
4. Very Often
5. Always or Almost Always
Physical Activity
8. I include foods that are high in fiber in my diet
1. I engage in moderate physical activity outside
on a daily basis (i.e. whole grain breads and
of work for at least 20 to 30 minutes at least 5
cereals, beans, etc.)
days of the week.
1
2
3
4
5
1
2
3
4
5
9. I maintain a healthy weight within the
2. My physical activity includes stretching,
recommendations specified by a health care
aerobic activity, and strength conditioning.
professional.
1
2
3
4
5
1
2
3
4
5
3. I use alternative modes of transportation
10. I avoid eating foods that are high in fat such as
whenever possible to and from various
whole milk, fried foods, fatty meats, etc.
locations (i.e. stairs instead of elevator, biking
or walking instead of driving).
1
2
3
4
5
1
2
3
4
5
General Health
4. I take the health benefits of physical activities
11. I avoid the use of tobacco products (cigarettes,
and their lasting impact seriously.
smokeless tobacco, cigars, and pipes) and limit myself
to 5 drinks of alcohol a week. (beer, liquor, wine)
1
2
3
4
5
1
2
3
4
5
5. I enjoy sedentary activities rather than physical
activities.
12. I examine my breasts or testes on a monthly basis.
1
2
3
4
5
1
2
3
4
5
Nutrition
13. I protect my skin from sun damage by using
6. I eat at least five servings of fruits and
sunscreen, wearing hats, and/or avoiding
vegetables every day (one serving equals one
tanning booths and sunlamps.
half cup).
1
2
3
4
5
1
2
3
4
5
14. I visit my dentist every six months for regular
check ups.
7. I eat at fast food restaurants less than three
times per week.
1
2
3
4
5
1
2
3
4
5
1