ADULT HEALTH ASSESSMENT

In general, how would you rate your health?

Do you have a medical provider that you see regularly?

Do you have any hearing problems for which you need help such as a hearing aid or TTY (teletypewriter)?

Are you currently pregnant?

In the last 7 days, how often did you exercise for at least 20 minutes in a day? 0 Days 1 to 2 Days 3 to 6 Days Every day -- select an option --

How many alcoholic drinks (like wine, beer, mixed drinks) do you have in a normal week? None 1 to 6 7 to 13 14 or more -- select an option --

Do you use tobacco products including cigarettes, smokeless tobacco, cigars, e-cigarettes?

Have you fallen in the last 6 months?

Over the past 2 weeks, how often have you felt down, depressed or hopeless? Not at all Several days More days than not Nearly every day -- select an option --

Over the past 2 weeks, how often have you felt little interest or pleasure in doing things? Not at all Several days More days than not Nearly every day -- select an option --

How stressful is your life right now? Not at all stressful Somewhat stressful Really stressful -- select an option --

During the past 4 weeks, did any medical problem keep you from being able to work or do any activities in your normal day?

Do you have a disability?

In the past 7 days, how much pain have you felt? None Some A lot -- select an option --

How many prescription drugs do you take? None 1 to 3 4 to 6 Greater than 6 -- select an option --

How many times in the last 6 months have you been to the emergency department? None 1 to 2 3 or greater -- select an option --

How many times were you hospitalized in the last 12 months? None 1 to 2 3 or greater -- select an option --

Do you need assistance with the following activities? (Select all that apply)? Bathing Dressing Brushing Hair / Teeth Eating Getting out of bed or chair Walking Using the bathroom Climbing Stairs None of the above

Do you need any medical equipment?

Do you have access to transportation for medical appointments?

Do you need help with food, clothing, housing, or utilities?

How long has it been since you last visited a dentist or dental clinic? Within the last year Between 1 to 2 years Between 3 to 5 years More than 5 years Never -- select an option --

What is your main health concern right now?

Do you have any of the following health conditions? (Select all that apply) Asthma Cancer Diabetes Liver Problems Heart Problems Swollen Legs Circulation Problems Kidney Disease High Blood Pressure Lung issues (COPD, Emphysema, fibrosis, etc.) Mental health concerns (anxiety, depression, biploar, schizophrenia, etc.) Neurological (stroke, Parkinson’s, epilepsy, headache, etc.) Other None of the above

How confident are you that you can control and manage, most of your health problems? Very confident Somewhat confident Not very confident I do not have any health problems -- select an option --