On Disk Monthly 66/odm66.zip/RISKSCAN.TXT

Text File | 1992-02-19 | 13KB | 368 lines

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.