Health Assessment – healthhammer.com

Step 1 of 6 – Personal Information

Let’s continue with a few questions about your health.

Click Next to move through the form.
When finished, click Submit.
You do not need lab results or provider records to complete this assessment. Those can be submitted later as a separate step.

Confidentiality Notice: Your health information is confidential, encrypted, and accessible only to you and authorized healthcare professionals. To learn more, read our Privacy Policy.

Unique ID

Date of Birth(Required)

Month

Day

Year

Sex assigned at birth(Required)

Male

Female

For accurate health calculations

Height – Feet(Required)

Height – Inches(Required)

Please answer questions about your personal and family health history.

Do you take medication for high blood pressure?(Required)

Yes

Has anyone in your immediate family (parents, brother, or sister) had a heart attack?(Required)

Yes

Skip Question

Questions regarding family history can be skipped. Providing this information can help make your assessment more accurate.

Did the heart attack in your immediate family occur in a female younger 65 or a male younger than 55?(Required)

Yes

Skip Question

Have you been diagnosed with diabetes or heart disease?(Required)

Yes

Have you been diagnosed with cancer or stroke?(Required)

Yes

How many years has it been since your last complete checkup with a physician(Required)

Is there anything about your health you'd like to change in the near future?

Please answer questions about lifestyle habits and behaviors that can affect your health.

Do you currently smoke cigarettes or use vaping products that contain nicotine or tobacco?(Required)

Yes

Do you plan to quit within 6 months?(Required)

Yes

Which of the following best describes your level of physical activity?(Required)

Inactive

Somewhat active

Active

-Inactive: no exercise in the past month -Somewhat Active: occasional or moderate exercise -Active: regular vigorous exercise ≥3x/week or moderate exercise ≥5x/week

How many drinks of alcohol do you have in a typical week?(Required)

How often do you wear your seatbelt when riding in a car?(Required)

Always

Sometimes

Never

Please answer questions about your personal and family history related to diabetes.

Have you ever given birth to a child weighing more than 9 pounds?(Required)

Yes

Have you had a parent that has been diagnosed with diabetes?(Required)

Yes

Skip question

Questions regarding family history can be skipped. Providing this information can help make your assessment more accurate.

Have you had a brother or sister that has been diagnosed with diabetes?(Required)

Yes

Skip question

Questions regarding family history can be skipped. Providing this information can help make your assessment more accurate.

Please answer questions about your stress, well-being, and satisfaction.

How would you describe your overall stress level?(Required)

Low

Medium

High

How satisfied are you with your life?(Required)

Very satisfied

Satisfied

Partly satisfied

Not satisfied

How satisfied are you with your job?(Required)

Very satisfied

Satisfied

Partly satisfied

Not satisfied

In the past 12 months, about how many days have you missed work due to health reasons?(Required)

How would you rate your overall health?(Required)

Excellent

Good

Fair

Poor

Do you take medications or sleep aids more than 3 times per month to help you sleep or relax?(Required)

Yes

These final questions provide additional support if you’re interested and help us improve the assessment. Your responses are optional.

Did you experience any issues completing this form

Yes

Please briefly describe the issue

Would you like additional resources or follow-up after completing this assessment

Yes

Request your personalized report, schedule a coaching call, or access other wellness resources.