Sample Health and Safety Risk Assessment

1
Physical Activity
1. I engage in moderate physical activity outside
of work for at least 20 to 30 minutes at least 5
days of the we ek.
1 2 3 4 5
2. My physical activity includes stretching,
aerobic activity, and strength cond itioning.
1 2 3 4 5
3. I use alternative modes of transportation
whenever possible to and from various
locations (i.e. stairs instead of elevator, biking
or walking instead of driving).
1 2 3 4 5
4. I take the health benefits of physical activities
and their lasting impact seriously.
1 2 3 4 5
5. I enjoy sedentary activities rather than physical
activities.
1 2 3 4 5
Nutrition
6. I eat at least five servings of fruits and
vegetables every day (one serving equals one
half cup).
1 2 3 4 5
7. I eat at fast food restaurants less than three
times per week.
1 2 3 4 5
8. I include foods that are high in fiber in my diet
on a daily basis (i.e. whole grain breads and
cereals, beans, etc.)
1 2 3 4 5
9. I maintain a healthy weight within the
recommendations specified by a health care
professional.
1 2 3 4 5
10. I avoid eating foods that are high in fat such as
whole milk, fried foods, fatty meats, etc.
1 2 3 4 5
General Health
11. I avoid the use of tobacco products (cigarettes,
smokeless tobacco, cigars, and pipes) and limit myself
to 5 drinks of alcoho l a week. (b eer, liquor, wine)
1 2 3 4 5
12. I examine my breasts or testes on a monthly basis.
1 2 3 4 5
13. I protect my skin from sun damage by using
sunscreen, wearing hats, and/or avoiding
tanning booths and sunlamps.
1 2 3 4 5
14. I visit my dentist every six months for regular
check ups.
1 2 3 4 5
On the answer sheet provided, please circle the number w hich best identifies your response to each
corresponding statement.
1. Never or Almost Never
2. Occasionally
3. Often
4. Very Often
5. Always or Almost Always
Sample Health Risk Assessment (HRA)
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