RISKSCAN ^CJUST FOR OUR SUBSCRIBERS During the last decade, we have all become more health conscious. Fitness and You, a program on this issue, is one way that On Disk Monthly has responded to this awareness. Presenting you with the opportunity to take advantage of a computer- generated, confidential health appraisal from Riskscan* is another. All you have to do is fill out and mail-in the questionnaire per the instructions in the "Here's What To Do" section below. First, let's take a closer look at the appraisal. ^CWHAT IS THE RISKSCAN PERSONAL RISK APPRAISAL? Using your answers to the questions that follow this explanation, Riskscan's state-of-the-art computer system will use its huge database of other respondents to compare your lifestyle and health risks to others in your age group and will generate a confidential Personal Risk Appraisal. Though the appraisal is not a substitute for your regular medical check-up and cannot be used to diagnose or predict medical problems, it will do the following: calculate your "Health Age" (an indication of your current health risks) and your "Achievable Health Age" (which tells you what your life span potential might be). Your confidential report will also tell you how you can increase your chances of living a longer, healthier life and what your health risks are, and will suggest programs and/or screening tests based on your score. ^CTAKE ADVANTAGE OF A SPECIAL REDUCED FEE ^COFFERED ONLY TO ODM SUBSCRIBERS Riskscan has agreed to a special fee of only $5.80 for processing each questionnaire sent in by On Disk Monthly subscribers. In addition to receiving an attractively designed Personal Risk Appraisal that contains all of the features listed above, you will receive a FREE copy of Riskscan's "Keeping Fit" newsletter. If you don't want to try the appraisal right now, but are intrigued by it, call 1-800-243-0876 for more information or to receive a brochure about Riskscan. ^CHERE'S WHAT YOU NEED TO DO 1) Print out the following questionnaire. 2) Answer each question honestly and in the numbered order. 3) Then mail the completed questionnaire and $5.80 to: ATTN: Kathy Harjehausen Center for Health Programs Bureau of Business Practice 24 Rope Ferry Road, Dept. ODM Waterford, CT 06386 ^CPlease allow for a 10-day turn around. ^CRISKSCAN QUESTIONNAIRE ^Cfrom Softdisk's ON DISK MONTHLY Issue #66 Reg. ID or SS# _____________________________________________ Name (last, first, initial) ________________________________ Address ____________________________________________________ City ______________________ State _____ Zip ________________ Phone (_____)_____________ day, or (_____)____________ night Today's Date _____/_____/_____ Birthdate _____/_____/_____ These questions must be answered in order to accurately appraise your current health risk. Age _______ Sex ________ Race (1-Caucasian, 2-Black, 3-Hispanic, 4-Oriental, 5-American Indian, 6-Other) ________________________________ Height _____ ft., _____ in. Weight ________ lb. Check Insurance Type: Major Medical ___ Medicare/Medicaid ___ HMO ___ PPO ___ None ___ Other ___ Health Insurance Company Name ______________________________ ____________________________________________________________ For Office Use Only Org SFTDK Cla ___ Occ ___ Ins ___ Pro ___ Ret ___ Ref ___ Bat ___ ____________________________________________________________ FAMILY HISTORY 1. Have any of your blood relatives, such as grandparents, aunts, uncles, parents, brothers or sisters, had any of these conditions? (Circle all that apply.) a. Breast Cancer b. Colon or Rectal Cancer c. Stomach Cancer d. Coronary Heart Disease 2. Within your immediate family, have your parents, brothers or sisters had a heart attack or heart bypass surgery? a. Yes, at age 59 or BEFORE b. Yes, at age 60 or AFTER c. None of the above or don't know PERSONAL HISTORY 3. How long has it been since your last complete medical examination? a. ______ years b. Never or don't know .PA 4. Do you currently have a physician with whom you can discuss the results of this test? a. Yes b. No 5. Have you ever had a urine test which reported sugar in your urine? a. Yes b. No c. Not sure 6. Have you ever been told that you have diabetes? a. Yes, at age 40 or BEFORE b. Yes, at age 41 or AFTER c. No 7. Has a physician ever told you that your heart was enlarged? a. Yes b. No c. Not sure 8. Have you ever had a heart attack? a. Yes b. No 9. Have you ever had heart bypass surgery, angina, angioplasty, stroke or blood vessel surgery? a. Yes b. No 10. What is your blood pressure? a. Systolic ______(higher #) over ______(lower #) Diastolic If you don't know your EXACT blood pressure, circle one of the following: b. I know it is high c. I know it is borderline high d. I know it is about average e. I know it is low f. I don't know .PA 11. Have you ever been diagnosed as having any of these conditions? (Circle all that apply.) a. Coronary Heart Disease b. Stroke c. Lung Cancer d. Colon or Rectal Cancer e. Breast Cancer f. Bladder Cancer g. Pancreatic Cancer h. Stomach Cancer i. Cirrhosis of the Liver j. Diabetes k. Ulcerative Colitis l. Emphysema m. Pneumonia n. Prostatic Cancer (males only) For Women Only: o. Benign Breast Disease p. Cervical Cancer q. Uterine (endometrial) Cancer r. Ovarian Cancer 12. Have you had any of the following problems recently which you have NOT discussed with a physician? (Circle all that apply.) a. Rectal bleeding b. Change in bowel or bladder habits c. Black tarry stools d. Change in size or color of wart or mole e. Chronic cough or hoarseness f. Unplanned weight loss of 10 or more pounds in the past 2 months g. Coughing or spitting up blood h. Chest pain i. Shortness of breath j. Abnormal (irregular or rapid) pulse k. A lump in the breast l. Frequent indigestion, difficulty in swallowing For Women Only: m. Bleeding or discharge from nipples n. Unusually heavy or lengthy menstrual period o. Unexplained vaginal bleeding DIET AND EXERCISE 13. What is your serum cholesterol level? a. ________ (fill in level) If you don't know your exact level, circle one of the following: b. I know it is high c. I know it is about average d. I know it is low e. I don't know 14. Which of the following BEST describes your eating pattern? a. One serving of red meat and/or fried foods daily, more than seven eggs weekly, and daily consumption of butter, whole milk and cheese. b. Red meat four to seven times weekly, four to six eggs weekly, some margarine, low fat dairy products, cheese and/or fried foods. c. Poultry, fish, little or no red meat, three or less eggs weekly, some margarine, skim milk and skim milk products. 15. What is your overall level of activity? (Moderate exercise is four 60 minute walks per week, or regular swimming, or bicycling, etc.) a. Vigorous b. Moderate c. Little 16. Do/did you smoke a pipe or cigar regularly? a. Yes, I do now b. I did, but have stopped c. No, I never have 17. Do/did you smoke cigarettes? a. Yes, I do now b. I did, but have stopped c. No, I never have (skip to question 21) 18. How old were you when you started smoking cigarettes? a. ______ years 19. What is/was the average number of cigarettes you smoke(d) each day? a. ______ cigarettes 20. If you no longer smoke, how many years ago did you quit? a. ______ years ago ALCOHOL 21. How many alcoholic beverages do you drink in an average week? (Include each cocktail, glass of wine, can of beer, etc.) a. ______ drinks per week b. None STRESS 22. How well do the following traits describe you: COMPETITIVE, EASILY ANGERED, PRESSED FOR TIME, BOSSY? a. Very well b. Fairly well c. Not well .PA MOTOR VEHICLE SAFETY 23. About how many thousands of miles per year do you drive or ride in a car? a. ______ thousand miles per year 24. In what size car do you usually drive or ride? a. Full size b. Compact c. Subcompact 25. Do you frequently ride a motorcycle? a. Yes, without a helmet b. Yes, with a helmet c. No 26. How often do you wear a seatbelt or shoulder harness when riding in or driving a car? a. rarely or never b. frequently c. Always or almost always 27. How many tickets have you received for moving violations in the past 2 years? a. ______ tickets 28. Do you ever drive at speeds exceeding 30 miles an hour after having more than 3 drinks or ride with a drinking driver? a. Sometimes b. Almost never c. Never SCREENING TESTS 29. How recently have you had each of the following screening tests? (Indicate your answer using one of the following numbers: 1=within the past year, 2=within the past 2 years, 3=within the past 3 years, 4=four or more years ago and 5=never.) a. Blood Pressure Check ______ b. Cholesterol ______ c. Blood Glucose ______ d. Electrocardiogram ______ e. Chest X-ray ______ f. Hemoglobin Test ______ g. Digital Rectal Exam ______ h. Sigmoidoscopy ______ i. Occult Blood Test ______ For Women Only: j. Breast Physical Exam ______ k. Mammogram ______ l. Pap Test ______ m. Pelvic Exam ______ .PA FOR WOMEN ONLY (Men proceed to question #37) 30. How old were you when your periods started? a. ______ years old 31. If you have had children, how many children have you had? a. ______ children 32. Do you take birth control or estrogen pills for any reason? a. Yes b. No 33. Do you examine your breasts monthly to check for lumps? a. Yes b. No 34. Have your monthly periods stopped permanently? a. Yes b. No c. Not sure 35. Have you had a hysterectomy? a. Yes b. No 36. If both of your ovaries have been removed, how old were you at the time? a. ______ years old AREAS OF SPECIAL INTEREST Check which of the following health areas would be of interest to you or your spouse. Self Spouse 37. Family Doctor or Specialist ____ ____ 38. Comprehensive Medical Check-up ____ ____ 39. Comprehensive Cardiovascular Evaluation ____ ____ 40. Blood Pressure/Cholesterol Check ____ ____ 41. Reducing Risk of Heart Attack/Stroke ____ ____ 42. Weight Management Program ____ ____ 43. Stress Management Program ____ ____ 44. Cancer Risk Reduction Program ____ ____ 45. Stop Smoking/Tobacco Stoppers Program ____ ____ 46. Fitness Assessment/Custom Exercise Program ____ ____ 47. Seniors' Programs ____ ____ 48. Women's Health Programs ____ ____ 49. Low Back Care ____ ____ 50. Exercise/Aerobic Program ____ ____ 51. Sports Medicine ____ ____ Questions 52 and 53 are OPTIONAL and are used as statistical data only: 52. Total household income: a. Less than 15,000 d. $35,000-$44,999 b. $15,000-$24,999 e. $45,000-$54,999 c. $25,000-$34,999 f. More than $55,000 53. Highest level of education completed: a. High School d. Graduate School b. Some College e. None of the above c. College TO BE COMPLETED BY A PHYSICIAN OR HEALTH PROFESSIONAL (This is an optional section.) 54. Height ______ inches 55. Weight ______ pounds 56. Blood Pressure ______/______mm Hg 57. Body Fat ______% Skin Folds, 3-site ______mm Skin Folds, 7-site ______mm 58. Total Cholesterol ______mg/dl 59. HDL Cholesterol ______mg/dl 60. Triglycerides ______mg/dl 61. LDL Cholesterol ______mg/dl 62. Blood Glucose ______mg/dl 63. Max VO2 ______ml/kg/min. This custom Health Risk Appraisal instrument was developed in association with Resource Center Enterprise. This special On Disk Monthly offer was made possible through cooperation between the Bureau of Business Practice and Softdisk Publishing.