Class Climate online-survey - Health Assessment 2

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 Date:

/ /

1.2 Full Name:

1.3 Address to include Street/P.O. Box, City, State, Zip:

1.4 Gender:

Female

Male

1.5 Cell Phone:

1.6 Email:

1.7 DOB:

/ /

1.8 Age:

1.9 CCC Affiliation:

Employee

Student (on-campus)

Student (off-campus)

1.10 Other Affiliation:

High School Participant

Community Participant

2Pretesting Data: Must be completed by Test Administrator

2.1 Height (ft.)

2.2 Current Weight (lbs.)

2.3 Blood Pressure:

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.

3.1 Do you smoke?

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

3.7 Please tell us your desired weight goals:

3.8 Do you need nutritional counseling?

Yes

No

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

Yes

No

3.10 How active are you?

sedentary (little to no physical activity)

light activity (walking around the house, sitting at computer, shopping, washing dishes, eating, and/or preparing food)

moderate activity (sweeping the floor, walking briskly, slow dancing, vacuuming, washing windows, and/or shooting a basketball)

vigorous activity (running (5 mph >), swimming, shoveling, soccer, jumping rope, and/or carrying heavy loads, (i.e. bricks/lifting weights)

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 Emergency Contact:

4.2 Emergency Contact:

THANK YOU!