2. Adaptive Form Title
  3. First Name
  4. Last Name
  5. Mother’s maiden name
  6. Contract Number
  7. Work Agency
  8. Gender
  9. Date of birth
  10. Phone number
  12. Adaptive Form Title
  14. 1. Mark the highest grade or level of school completed:
  15. 2. In general, how do you consider your current health status?
  16. 3. Compared to last year, how would you describe your current health status?
  17. 4. Do you smoke?
  18. 5. Do you plan on quitting?
  19. 6. When would you be willing to quit?
  20. 7. Would you like to make changes in your eating habits?
  21. 8. When would you be willing to start making changes in your eating habits?
  22. 9. Do you complete at least 2 ½ hours of physical activity each week such as walking, running, cycling, swimming or aerobics?
  23. 10. Do you plan on starting a physical activity?
  24. 11. When would you be willing to start a physical activity?
  25. 12. When was the last time you had a complete physical exam? (Including laboratory tests and routine examinations)
  26. 13. When was the last time you performed any of the following tests: sigmoidoscopy or colonoscopy?
  29. 14. Mammogram
  30. 15. Pap Smear Test
  31. 16. How often do you perform a breast self-exam? (Optional)
  32. 17. Are you pregnant? (Optional)
  34. 18. Prostate exam (Optional)
  35. 19. PSA blood test (Optional)
  36. 20. How often do you perform a testicular self-exam? (Optional)
  38. Table
  39. 22. Would you like to be contacted by phone by a nurse to provide educational support related to the management of your disease or condition?
  40. Identify up to 5 topics of interest:
  41. Adaptive Form Title
  42. I hereby consent to the Education and Prevention Department of Humana and their representatives to the administration of wellness screening tests:
  43. I understand that:
  44. Signature
  45. Date
  46. Submit

Required

Demographic Data

Health and wellness screening

This screening is intended to help us develop a health and wellness program of quality and excellence in the workplace. Select the answer that corresponds:

If your biological sex is female, please answer questions #14 through #17, then proceed to question #21. If your biological sex is male, proceed to question #18.

How long ago was your last preventive examination?

How long ago was your last preventive examination?

21. Check the following list of conditions and diseases to identify if you have been diagnosed by your doctor and whether you use any medication to treat that condition.

Condition or disease

Do you use medication?

Consent form and liability release

• The individual results of this screening will not be shared with my employer. It will be used exclusively by Humana, in compliance with federal and state laws of health information management, for their clinical and educational programs.

• This screening service is offered for my benefit. My participation is completely voluntary.

• The screening is not meant to replace the care of my personal physician.

• I may receive results that could be considered “abnormal” along with an explanation of the results. Screenings tests can give false results for a variety of reasons.

• My doctor is best able to interpret the results of these tests based on his/her understanding of my medical history.