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Health Risk Assessment

Please answer the following questions to the best of your ability.  

If you see that your address, phone number or other information in the heading is incorrect, please enter updates in the fields provided.




    
    
  • Alcohol Dependency/Misuse
  • Alzheimer's/Dementia
  • Anxiety
  • Arthritis
  • Asthma
  • Cancer
  • Chronic Obsutructive Pulmonary Disease (COPD)
  • Chronic Pain
  • Congestive Heart Failure (CHF)
  • Depression
  • Diabetes
  • End Stage Renal Disease (Dialysis)
  • Heart Disease
  • Hearing Impairment
  • High Blood Pressure
  • HIV/AIDS
  • Memory Problems
  • Obesity
  • Opioid Dependency/Misuse
  • Organ Transplant
  • Parkinson's Disease
  • Paralysis
  • Peripheral Vascular Disease
  • Schizophrenia
  • Seizures
  • Smoking Dependency/Misuse
  • Stroke
  • Substance Abuse
  • Thyroid Disease
  • Vision Impairment

Thanks for taking this survey!