THC – Annual Health Assessment

-------Physical Activity-------

How many days a week do you exercise? [select name="Q1" value="|Never|Rarely Ever|1-2 Days Per Week|3-4 Days per week|5 or More Days"]

How many minutes do you exercise per day? [select name="Q2" value="|Not Applicable|Less than 30|30-60 Minutes|60-90 Minutes|More than 90 Minutes"]

How Intense is your typical exercise? [select name="Q3" value="|Not Applicable|Light (like stretching or slow walking)|Moderate (like brisk walking)|Heavy (like jogging or swimming)|Very heavy (like fast running or stair climbing)"]


-------Tobacco Use-------

Do you Smoke? [select name="Q4" value="|No|Yes"]

Do you Vape? [select name="Q5" value="|No|Yes"]

Do you use smokeless Tobacco? [select name="Q6" value="|No|Yes"]

Are you interested in quitting? [select name="Q6a" value="|No|Yes"]


-------Alcohol Use-------

Have you used alcohol in the past 7 days? [select name="Q7" value="|No|Yes"]

On days when you drank alcohol, how often did you have 4 or more drinks? [select name="Q8" value="|Not Applicable|Never|Once during the 7 days|2-3 times during the 7 days|More than 3 times during the 7 days"]

Do you ever drink and drive or ride with someone who is drinking and driving? [select name="Q8a" value="|No|Yes"]


-------Nutrition-------

How many servings of fruits and vegetables do you eat per day? [select name="Q9" value="|None|1-2 Servings|3-5 Servings"]
[comment memo="(1 serving = 1 cup of fresh vegetables, ½ cup of cooked vegetables, or 1 medium piece of fruit. 1 cup = size of a baseball.)"]

How many servings of high fiber or whole grain food do you eat per day? [select name="Q10" value="|None|1-2 Servings|3-5 Servings"]
[comment memo="(1 serving = 1 slice of 100% whole wheat bread, 1 cup of whole-grain or high-fiber cereal, ½ cup of cooked cereal such as oatmeal, or ½ cup of cooked brown rice or whole-wheat pasta.)"]

How many servings of fried or high-fat foods do you eat per day? [select name="Q11" value="|None|1-2 Servings|3-5 Servings"]
[comment memo="(Examples: include fried chicken, bacon, French fries, potato chips, corn chips, doughnuts, creamy salad dressings, and foods made with whole milk, cream, cheese or mayonnaise.)"]

How many sugar-sweetened drinks do you have per day? [select name="Q12" value="|None|1-2 Servings|3-5 Servings"]
[comment memo="(Examples: Pop, Kool-aid, sweet tea, coffee with sugar and cream.)"]


-------Depression-------

In the past 2 weeks, how often have you felt down, depressed or hopeless? [select name="Q13" value="|Never|All of the time|Some of the time|Most of the time"]

In the past 2 weeks, how often have you felt little interest or pleasure in doing things? [select name="Q14" value="|Never|All of the time|Some of the time|Most of the time"]

Have your feelings caused you distress or interfered with your ability to get along socially with family or friends? [select name="Q15" value="|No|Yes"]


-------Anxiety-------

In the past 2 weeks, how often have you felt nervous, anxious or on edge? [select name="Q16" value="|Never|All of the time|Some of the time|Most of the time"]

Are you able to control your worrying? [select name="Q17" value="|Never|All of the time|Some of the time|Most of the time"]


-------High Stress-------

How often is stress a problem for you in handling such things as your health, your family or social relationships and your finances? [select name="Q18" value="|Never|All of the time|Some of the time|Most of the time"]


-------Social and Emotional Support-------

How often do you get the social and emotional support you need: [select name="Q19" value="|Always|Usually|Sometimes|Rarely|Never"]


-------Pain-------

In the past 7 days, how much pain have you felt? [select name="Q20" value="|None|Some|A Lot"]

What is your current pain level? [select name="P1" value="|None|1|2|3|4|5|6|7|8|9|10"]


-------General Health-------

In general, would you say your health is? [select name="Q21" value="|Excellent|Very Good|Good|Fair|Poor"]

How would you describe the condition of your mouth and teeth, including false teeth and dentures? [select name="Q22" value="|Excellent|Very Good|Good|Fair|Poor"]


-------General Health-------

In the past 7 days have you needed help with daily living activities? Examples include: eating, getting dressed, bathing, walking, housekeeping, shopping, food preparation or taking your medications. [select name="Q23" value="|No|Yes"]

How many hours of sleep do you get a night? [select name="Q24" value="|less than 4|4-6|6-8|more than 8"]

Do you snore or has anyone told you that you snore? [select name="Q25" value="|No|Yes"]

Do you feel sleepy during the daytime? [select name="Q26" value="|Always|Usually|Sometimes|Rarely|Never"]


-------General Health-------

What is your height without shoes?

Body Mass Index (BMI)
[select name="Height_ft" value="|1|2|3|4|5|6|7"]’ [select name="Height_in" value="|1|2|3|4|5|6|7|8|9|10|11"]”
[calc value="Height=((Height_ft)*(12))+(Height_in)"]
[text name="Weight"] <-- Weight in pounds
BMI Calculations
Class --> [calc memo="class" value="score=(Weight)*(703)/((Height)*(Height));score>59.9999?'Super-super obesity or class V obesity':score>49.9999?'Super-obesity or class IV obesity':score>39.9999?'Extreme obesity or class III obesity':score>34.9999?'Obesity class II':score>29.9999?'Obesity class I':score>24.9999?'Overweight':score>18.4999?'Normal':score>16.4999?'Underweight':'Severely underweight'"]
BMI --> [calc memo="bmi" value="score1=score.toFixed(1)"]

[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
reference: 
Obesity Evidence at [link url="http://www.aafp.org/afp/2010/1015/p974.html" memo="#1"] Delaet (2010) Am Fam Physician 82:974-5[/conditional]


-------Blood Glucose-------


If your glucose was checked, what was your fasting blood glucose (blood sugar) level the last time it was checked? [select name="Q27" value="|Normal (Below 100)|Borderline High (100-125)|High (126 or higher)|don’t know/Not sure"]


-------Other Providers-------

Please list any specialists that you see along with their name, phone number and the last time that you saw them (approximately)
Cardiologist (Heart) [text name="speacialist_1" default=""]
Dentist (teeth) [text name="speacialist_2" default=""]
Endocrinologist (thyroid/diabetes) [text name="speacialist_3" default=""]
Gastroenterologist (stomach/liver) [text name="speacialist_4" default=""]
Nephrologist (Kidney) [text name="speacialist_5" default=""]
Oncologist (Cancer) [text name="speacialist_6" default=""]
Ophthalmologist (Eyes) [text name="speacialist_7" default=""]
Podiatrist (foot) [text name="speacialist_8" default=""]
Pulmonologist (Lungs) [text name="speacialist_9" default=""]
Psychiatrist (Mental Health) [text name="speacialist_10" default=""]
Orthopedics (Bone and Joint) [text name="speacialist_11" default=""]
Other [text name="speacialist_12" default=""]

When was your last Colonoscopy? [text name="other_1" default=""]
Where was your last Colonoscopy? [text name="other_2" default=""]

When was your last Pap smear (Women only)? [text name="other_3" default=""]
Where was your last Pap smear (Women only)? [text name="other_4" default=""]

When was your last Mammogram? [text name="other_5" default=""]
Where was your last Mammogram? [text name="other_6" default=""]