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  5. Health Assessment Health Risk Assessment
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Exit Survey
 
 
What is your gender
 
Male
 
Female

 
 
 
What is your age category?
 
18- 25 years old
 
26- 31 years old
 
32- 39 years old
 
40- 47 years old
 
48- 55 years old
 
> 55 yearsold
 
 
 
Do you smoke or use any tobacco
 
Yes
 
No
 
 
 
How much do you smoke?
 
Less than a pack a day
 
1 pack a day
 
More than one pack a day
 
 
 
Do you drink alcohol?
 
Yes
 
No
 
 
 
How much alcohol do you drink?
 
Occassionally
 
1 drink daily
 
2 drinks daily
 
3 drinks daily
 
4 or more drinks daily
 
 
 
Do you regularly excercise?
 
Yes
 
No