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Healthy for Life - First-step Therapy - Dr. Ray D. Strand
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Health Risk Assessment
Please answer the questions below to complete your Health Risk Assessment.
Section 1 - Medical and Family History
What is your sex?
Male
Female
What is your age?
What is your birthdate?
What is your height? (in inches)
What is your weight in pounds?
What is your waist measurement? Best to measure 1 or 2 inches below your belly button (umbilicus).
Females: less than 26 inches
Females: less than 30 inches
Females: less than 34 inches
Females: greater than 34 inches
Males: less than 32 inches
Males: less than 36 inches
Males: less than 40 inches
Males: greater than 40 inches
Have you ever had cancer?
Yes
No
Do you have Diabetes?
Yes
No
Have you ever had gestational diabetes? (Females only)
Yes
No
Have you ever had elevated fasting blood sugar greater than 100 mg/dl (>6.0 mmol/L)
Yes
No
Do you have high blood pressure?
Yes
No
Have you ever had borderline elevated blood pressure? Systolic (high number) > than 145 or Diastolic (low number) < 85.
Yes
No
Have you ever been diagnosed with coronary artery disease or have you ever had a heart attack?
Yes
No
Have you ever had a stroke or a transient stroke?
Yes
No
Have you ever had a premalignant or precancerous growth?
Yes
No
Do you have any family history (siblings, parents, grandparents, aunts, or uncles) of any of the following:
Diabetes
Heart Attacks or Bypass Surgery
Stroke
Macular degeneration
Alzheimer’s dementia or any form of dementia
Arthritis (significant)
Serious Depression
Cancer

Health Concepts, PO Box 9226, Rapid City, SD 57709
Customer service: Supervisor@ReleasingFat.com.
© 1999, 2000, 2001, 2002, 2003, 2004 Ray D Strand, M.D. P.C.