Health Risk Assessment Printable Form

ID # ___ ___ ___
Health Risk Assessment

Date ___ ___ / ___ ___ /___
___ ___ ___
Client _____________________________________ Birth Date
___ ___ / ___ ___ /___ ___ ___ ___
Address ___________________________________ City______________ ST.____ Zip____________

Home Phone _______________________________ Cell Phone ______________________________
E-mail Address _________________________________________
02/24/2009 1:01 PM
Copyright 2007 by the AgriSafe Network
ID # ___ ___ ___
Health Risk Assessment

Date
___ ___ / ___ ___ /___ ___ ___ ___
INSURANCE QUESTIONS
These questions are optional
Source of insurance ...
I purchase my own health insurance.
I have health insurance from my own employment off the farm.
I have health insurance from a family members employment off the farm
I have insurance through Medicare, Medicaid, Veterans benefits, or other government program.
I do not have health insurance (skip to question 12)
Does your health insurance cover a yearly visit to a health care provider (doctor) for a routine check up?
Yes, it is 100% covered
Yes, but it would apply to my deductible
I dont know
Does your health insurance cover a yearly cholesterol screening test?
I dont know
Does your health insurance cover injuries that occur as a result of work on the farm?
I dont know
No
Are you satisfied with your health care coverage?
Yes
No
Do you carry a separate insurance policy to cover accidents or injuries that may result from work on the farm?
Yes
No
I dont know
How much do you spend for insurance premiums per year? ___________________
What is your deductible per year?___________________
FARM PROFILE
Including yourself, (principle farm operator), who currently lives in your home?
Relationship (Wife,son,etc.)
Age
Gender Relationship
Yourself
Person 2
Person 3
Person 4
Person 5
Person 6
02/24/2009 1:01 PM
____
____
____
____
____
____
M or F
M or F
M or F
M or F
M or F
M or F
______________
_______________
_______________
_______________
_______________
_______________
On Farm Work
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
ID # ___ ___ ___

What crops do you
grow?
Corn
Soybeans
Oats
Sorghum
Hay
Organic Crops
Other
Do you self-apply manure
on your farm?
Do you have an off farm
job?
Describe off farm work
Do you currently raise

Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes
No
Yes
No
Hours _______
Swine
Cattle
Cow/calf
Dairy
Chicken, eggs
Chicken, broilers
Turkeys
Horses
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Sheep
Yes
No
Other
Yes
No
Confinement
Confinement
Confinement
Confinement
Confinement
Confinement
Confinement
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
Do children (grandchildren, children of friends and family) under age 18 visit your farm?
Yes
No
Do these children work on the farm?
Yes
No
GENERAL HEALTH
Name of your primary health care provider? (Optional)
Examples: Doctor, Nurse Practitioner, Chiropractor,
__________________________________________
Please describe any general health problems you have at this time. :
Please list any prescription and/or over the counter medications you currently take daily or when needed.
If more space is needed, please write additional medications on the back of this page.
Name of medication
Reason for its use
1.
2.
3.
4.
1.
2.
3.
4.
HEALTH HISTORY
Do you or any family members (parents,
siblings, children) have any history of the
following diseases?
Asthma
Emphysema
Hay fever
Allergies
Lung cancer
Other lung problems
(specify type)
_______________
Heart disease
High blood pressure
Stroke
Diabetes
Kidney disease
Liver disease
02/24/2009 1:01 PM
YOU
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
FAMILY
MEMBER
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Specify Relationship
(parent, child, etc.)
No
No
No
No
No
No
No
3
ID # ___ ___ ___
HEALTH HISTORY (cont)

Cancer (specify type)
________________
Arthritis
Other (specify disease)
Yes
Yes
Yes
When did you last receive the following health

services:
Routine check-up/physical
Blood pressure check
Cholesterol check
Colorectal exam
Eye exam
Dental exam
Diabetes screening
Flu shot
Prostate exam (men only, over age 50)
Mammogram (women only)
No
No
No
Yes
Yes
Yes
No
No
No
Within the
year
1-3 years
ago
> 3 years
ago
Never
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
4
4
Pap smear (women only)
Colon cancer screening (over age 50)

Date of your last tetanus shot? (yyyy)
___ ___ ___ ___
HEARING
Has a physician or health care provider diagnosed you with hearing loss?
Yes
No
Do you wear a hearing aid?
Yes
No
How often do you experience

Ringing in the ears
Dizziness
Difficulty understanding conversations
If yes, when._____
Always
1
1
1
Sometimes
2
2
2
Never
3
3
3
When you are exposed to loud noise, how often do you

use hearing protection earplugs or earmuffs?
VISION
Have you been diagnosed with a vision loss or decline?
Yes
No
Do you wear eyeglasses?
Yes
No
Do you wear contact lenses?
Yes
No
When you work with power tools, how often do you eye protection?
Always
If yes, when_______
Sometimes
Never
SKIN CANCER
Have you ever been diagnosed with skin cancer?
Yes
No
If yes, when________
Do you have any pigmented spot(s) that have changed in size, color, contour, or thickness recently?
Are there any areas on your skin, which bleed or will not heal?
02/24/2009 1:01 PM
Yes
Yes
No
No
ID # ___ ___ ___
SKIN CANCER (cont)

Do you have any mouth sores or irritations?
Do you have any suspicious area(s) on your skin that you are
concerned about?
Yes
No
When outside, how often do you

Use tractors with a cab or canopy
Wear long sleeves when in sun
Use hat with a wide brim in the summer
Use sunscreen
Always
1
1
1
1
Sometimes
Never
2
2
2
2
3
3
3
3
MUSCULOSKELETAL
During the past 12 months have you had any ache, pain, morning
stiffness, or discomfort in your
Neck
Shoulder
Upper back
Elbow
Low back
Wrist/hand
Hip/thigh
Knee
Feet
Have any of the above musculoskeletal conditions prevented you
from working in the past 30 days?
Have any musculoskeletal conditions motivated you to see a health
care provider?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
No
Yes
No
RESPIRATORY
In the past 12 months, how often have you experienced any of
the following symptoms as a result of an on-farm exposure
(such as dust, fumes and vapors)?
Dry cough
Chest tightness
Cough w/ phlegm
Throat irritation
Wheezing chest
Sinus problems
Stuffy nose
Headache
Ears popping
What type(s) of farm work seem to
cause these symptoms?
Never
1
1
1
1
1
1
1
1
1
Less
than
monthly
2
2
2
2
2
2
2
2
2
Monthly
3
Weekly
4
Daily
5
3
3
3
3
3
3
3
3
4
4
4
4
4
4
4
4
5
5
5
5
5
5
5
5
a. _______________________ b.__________________
c. ________________________d.__________________
e._________________________f.__________________
02/24/2009 1:01 PM
ID # ___ ___ ___
RESPIRATORY (cont)
Is there a specific season when these symptoms are worse?
During the past 12 months, have you experienced flu-like symptoms
(shivering, muscle or joint aches, chest tightness, or headache) after
an extra heavy dust exposure, such as cleaning a grain bin, moving
or sorting hogs, or opening a silo?
How often do you wear respiratory protection when
exposed to dusty environments?
Always
Yes
No (if no, go to question 42)
Yes
No
Sometimes
Never
Not Applicable
For what exposures do you wear respiratory protection (list)_____________________________________
Please check the farming activities you have participated in the past 12 months:
Farming Activities
Cleaning grain bins
Unloading grain
Mixing and grinding feed
Unloading & feeding hay
Cleaning animal pens in barn
Other- Please explain
Feeding confinement animals

Cleaning confinement building
Working with poultry
Working with large animals
Hand harvesting fruits and vegetables
What type of respiratory protection do you use? (Circle one)

1-strap
disposable
mask
2-strap
disposable
mask
Half-mask
w/ cartridge
Full-mask
w/ cartridge
Where do you purchase your personal protective equipment?
Other (list)
None used
______________________________________
AGRICULTURAL PESTICIDE USE

Are agri-chemicals applied on your farm?
Yes
No (If no, go to the Farm Safety Section)
Please list up to 5 of the most heavily used herbicides,

insecticides, and/or chemical cleaners that you have used on your
farm in the past 12 months.
List others you frequently use:
______________________________________________________________
Indicate the frequency with which you currently use the following
types of personal protective equipment when working with farm
chemicals.
Eye protection
Chemical resistant boots
Chemical resistant disposable coveralls
Respirator
02/24/2009 1:01 PM
1. _________________________
2. _________________________
3. _________________________
4. _________________________
5. _________________________
Always
Sometimes
Never
Not
Applicable
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
4
4
4
4
4
ID # ___ ___ ___
AGRICULTURAL PESTICIDE USE (CONT)

When you self-apply pesticides, do you.
Wear clean, washed clothes every day
Change clothes immediately, if contaminated
Wash your work clothes separate from your
familys
Wash your hands before eating
Wash your hands before urinating
Wash your hands before smoking
1
1
1
2
2
2
3
3
3
4
4
4
1
1
1
2
2
2
3
3
3
4
4
4
FARM SAFETY & WELLNESS

In the past year, have you had a farm related injury that required medical
Yes
No
attention?
In the past year, how many farm-related injuries have you had that required medical attention?
Please put a check mark next to the statement that best describes your
smoking behavior.
Do you use smokeless tobacco?
_________
_____I have never smoked

_____I used to smoke, not anymore
_____I currently smoke
Yes
No
How many cups or ounces of caffeinated coffee, tea, or pop do you drink
daily?
How many servings of fruits and vegetables do you eat in 1 day.
How many servings of Protein do you eat in 1 day?
How many grams of fat do you eat in 1 day?
What kinds of breads and grains do you eat?
a. refined grain (white bread, rolls, regular pancakes and waffles,
white rice, typical breakfast cereals, typical baked goods).
b. Whole grain (whole-grain breads, brown rice, oatmeal,
whole-grain or high fiber cereals.
How many days in a week do you get at least 30 minutes of continuous
exercise such as brisk walking, jogging, active sports, swimming, aerobic
dance, biking or gardening, exclusive of farm work?
Circle the one you eat the most.

a. refined grain
b. whole grain
c. equal combination of both
Do you routinely wear a seat belt when you are riding in or driving a
vehicle?
Do you drink your water from a private well?
Yes
No
Yes
No
(if no, skip the next question)
Has your well been tested in the past 12 months?

Do you have a fire extinguisher in your home?
Yes
Yes
No
No
Do you have a fire extinguisher in your farm equipment?
Yes
No
Please circle the equipment with a fire extinguisher.
Combine
Do you have working smoke alarms in your home that you check
regularly?
Yes
No
Do you have working carbon monoxide detectors in your home?
Yes
No
Have you had your home tested for radon?
Yes
No
02/24/2009 1:01 PM
Tractor
Other
ID # ___ ___ ___
Stress/Depression/Coping
In the last month, how often have you felt that you were unable to control the important things in your life?
____Never ____Almost never ____Sometimes ____Fairly Often ____Very often
In the last month, how often have you felt confident about your ability to handle your personal problems?
In the last month, how often have you felt that things were going your way?
In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?
Over the past 12 months has you personal level of stress:
Decreased
Remained the Same
Increased
During the past month:

a ) Have you often been bothered by feeling down, depressed, or hopeless?
YES
NO
b) Have you often been bothered by little interest or pleasure in doing things?
YES
NO
c) Have you been hit, kicked, punched, or otherwise hurt by someone in the past year?
YES
NO
Do you feel safe in your current relationship?
YES
NO
Is there a partner from a previous relationship who is making you feel unsafe now?
YES
NO
Who would you identify as your primary support person(s)?

(Mark as many as are appropriate)
Spouse___ Parent ____ Sibling _____ Friend _____ Pastor/Priest____ God____
No one_____ Child____ Other ____ (please specify_________________________)
Do you have any concerns you would like to discuss with the nurse?
Yes
No
If yes, please specify:
THANK YOU FOR COMPLETING THIS FORM.

PLEASE TAKE THIS WITH YOU WHEN YOU GO TO YOUR CLINIC SCREENING.
02/24/2009 1:01 PM

Health Risk Assessment Printable Form

Caricato da

Informazioni sul documento

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Health Risk Assessment Printable Form

Caricato da

Copyright:

Formati disponibili

ID # ___ ___ ___