Lifescan Health Risk Appraisal

LifeScan has been created to help you learn more about the health risks you might be taking each day. The data used by this program have been collected from literally millions of death certificates. Over the past twenty years, millions of Americans have died prematurely. Carefully supervised research projects have shown the majority of these deaths were the direct result of lifestyle choices.

Instructions:

Answer all the questions to the best of your knowledge.

General Information

  • Gender:
  • Race/Origin:
  • Age:
  • Height:
  • Feet
    Inches

  • Weight:
  • Lbs.

  • Body Frame Size
  • Enter your blood pressure:
  • Systolic (High Number) (Enter 0 if Unknown)
    Diastolic (Low Number) (Enter 0 if Unknown)

  • Enter your TOTAL cholesterol level:
  • mg/dl(Enter 0 if Unknown)

  • Enter your HDL cholesterol level:
  • mg/dl(Enter 0 if Unknown)

  • Do you have diabetes?
  • Did your mother, father, sister
  • Smoking

  • How would you describe your smoking habits?
  • How many cigars do you usually smoke per day?
  • cigars per day

  • How many pipes of tobacco do you usually smoke per day?
  • pipes per day

  • How many times per day do you usually use smokeless tobacco? (Chewing tobacco, snuff pouches, etc)
  • times per day

  • How many cigarettes per day do you usually smoke?
  • cigarettes per day

    Former Smoker

    Answer these two questions if you selected "Used to Smoke"

  • How many years has it been since you smoked fairly regularly?
  • years

  • What is the average number of cigarettes per day that you smoked in the two years before you quit?
  • cigarettes per day

    Traveling

  • In the next 12 months, how many thousands of miles will you probably travel by motorcycle, car, truck, or van?
    (NOTE: U.S. Average = 10,000 miles)
  • ,000 (thousands of miles)

  • On a typical day, how do you usually travel?
  • What percent of time do you usually buckle your seat belt when driving or riding?
  • On the average, how close to the speed limit do you usually drive?
  • How many times in the last month did you drive or ride when the driver probably had too much alcohol to drink?
  • times last month

    Drinking

  • How many drinks of alcoholic beverages do you have in a typical week?
  • Bottles or cans of beer
    Glasses of wine
    Wine coolers
    Mixed drinks or shots

    Women's Section

  • At what age did you have your first menstrual period?
  • years (Enter 0 if hasn't occured)

  • How old were you when your first child was born?
  • years (Enter 0 if no children)

  • How long has it been since your last breast x-ray?(Mammogram)
  • How many women in your natural family (mother and sister only) have had breast cancer?
  • women

  • Have you had a hysterectomy? (Removal of uterus)
  • How long has it been since you had a pap smear for cancer?
  • How often do you examine your breasts for lumps?
  • About how long has it been since you had your breasts examined by a physician or nurse?
  • Men's Section

  • About how long has it been since you had a rectal or prostate exam?
  • Physical Activity

  • In the average week, how many times do you engage in physical activity (exercise or work lasting at least 20 minutes and hard enough to make you breathe heavier and your heart beat faster)?
  • Nutrition

  • How often do you drink at least a quart of water a day?
  • When preparing meals, how often do you use waterless and greaseless cookware?
  • How often do you eat several servings of breads, cereals, rice and pasta daily?
  • How often do you eat and drink low fat dairy products daily?
  • How often do you select lean cuts of meat, poultry and fish prepared with a minimum of fat?
  • How often do you eat a wide variety of foods to ensure adequate vitamins and minerals?
  • How often do you include whole grains, raw fruits and vegetables, beans or peas in your daily diet?
  • How often do you have a meatless meal at least once a week?
  • How often do you limit your intake of salt?
  • How often do you limit your intake of sugar?