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Home > Occupational Health > Darden TEP Health Questionnaire > Darden TEP Health Screening Questionnaire

Darden TEP Health Screening Questionnaire

Please Read and Initial Below

1) I wish to participate in the Human Performance Profile Assessment. Testing will include blood pressure measurement, height, weight, waist measurement and a venipuncture blood draw to measure my blood values including total cholesterol, HDL, LDL, Triglycerides and glucose. THIS IS A FASTING BLOOD TEST

2) I understand this is a screening test only, and is not a diagnosis

3) I have the responsibility for follow -up to confirm the results of the screening and to obtain further medical help if needed.

4) I give permission for UVA-WorkMed to view my personal risk factors from the screening and the online questionairre to help me reduce my health risks and help improve my human performance. I UNDERSTAND THE FOCUS FOR THIS TESTING IS HEALTH EDUCATION FOR ME AND TO ENCOURAGE ME TO UNDERSTAND AND TAKE OWNERSHIP OF MY HEALTH STATUS. THIS PROFILE DOES NOT SUBSTITUTE FOR A CHECK-UP OR PHYSICAL EXAM THAT I GET FROM A DOCTOR OR NURSE. IT WILL ONLY GIVE ME SOME INDICATION OF CERTAIN POTENTIAL RISKS TO MY HEALTH.

5) I acknowledge a copy of the HIPAA Notice of Privacy Practices for the University of Virginia Health System will be made available to me at the check-in station on the day of my health assessment.

Date of Birth  
/ /  
  • For the following Exercise questions:

Please indicate if you are currently engaged in the following:

For the following questions your answers should reflect your current habits.

Fat Intake   Indicate the kind of foods you usually eat (Higher Fat or Animal-based Fats--examples: hamburgers, hotdogs, cheese, whole milk, cake, pastry, ice cream, fried foods, many fast foods. Lower Fat or Plant-based Oils- examples: lean meat, skinless poultry, fish, skim or low-fat dairy, fruits, vegetables, legumes, nuts, seeds, oils)





Fruits - How Many Servings Do You Eat Daily   Serving= 1/2 cup cut up fruit, 1 medium size whole fruit, or 3/4 cup of 100% juice





Vegetables- How Many Servings Do You Eat Daily?   Serving = 1 cup fresh leafy greens, 1/2 cup cut up vegetables, cooked or raw.





Added Sugar Intake-How Many Servings Do You Eat Daily?   Added Sugars Include: regular soft drinks, desserts, ice cream, sweetened yogurt, candy, pastries, sweetened cereal, fruit drinks, caloric sweetners (table sugar, honey, syrup, etc.)





Alcoholic Drinks: How Many Alcoholic Drinks Do You Usually Have Per Week   One drink = 12oz beer, 5oz wine, or 1.5oz liquor





Smoking Status  






How Well Do You Feel You Are Coping With Your Current Stress Load?