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Wellness Inventory -- Section I

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Personal Health History

Question Yes No Don't Know
or N/A
1. Have any of primary relatives (father, mother, siblings) suffered coronary or other atherosclerotic disease prior to age 55?
2. Do any of your primary relatives have diabetes?
3. Do any of your primary relatives have osteoporosis?
4. Have any of your primary relatives had cancer?
5. Do any of your primary relatives have high blood pressure?
6. Do any of your primary relatives have high cholesterol?
7. Is your total cholesterol > or = to 20 mg/dl?
8. Is your blood pressure > or = to 140/90 mm Hg?
9. Do you have medical health exams once a year?
10. Are you obese (>20 lbs over average weight?)
11. Do you smoke cigarettes?
12. Would you rate yourself as a physically inactive person?

    Your Score

What your score means: Scoring to assess risk for developing chronic diseases

< 20 High risk
21 - 29 Moderate risk
> 30 Low risk

Please make note of your score for this section and move on to the next section.

 

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