Thank you for participating in the Coahoma Community College Fit for Life Healthy Campus Initiative Health Assessment.  Please take a few minutes to complete this assessment.  Your responses are confidential and will be kept in your file for the Fit for Life staff members to review.

1Personal Information

1.1

/ /

1.2


1.3


1.4Gender:

1.5


1.6


1.7

/ /

1.8


1.9CCC Affiliation:

1.10Other Affiliation:

2Pretesting Data:  Must be completed by Test Administrator

2.1


2.2


2.3


3Health Risk Assessment:  To provide you with the best service possible, it is important for us to review issues that might impact your health.  This form is confidential and will be kept in your file for CCC Fit for Life Healthy Campus Initiative staff members to review.

3.1Do you smoke?

3.2Are you exposed to tobacco products at home or work?

3.3Have you or a family member ever been told that you have diabetes?

3.4Have you or a family member ever been told that you have high blood pressure and heart problems?

3.5Have you or a family member ever been told that you have high cholesterol?

3.6Women Only: Are you pregnant or did you have a baby less than six weeks ago?

3.7


3.8Do you need nutritional counseling?

3.9Have you been exercising regularly for the past 6 months?

3.10How active are you?

 
 

4Emergency Contact Information: Please provide the name, phone number, and relationship of at least two people we may contact in case of an emergency.

4.1


4.2


 
 
 

THANK YOU!