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A health risk and safety assessment questionnaire is a tool used to identify potential health and sa

Identify the individual or group being assessed.

Record the date of the assessment.

Collect contact information (name, phone number, email).

Note the assessor's name and qualifications.

Inquire about any pre-existing medical conditions.

Document any current medications being taken.

Ask about allergies (food, medication, environmental).

Assess family health history relevant to the individual.

Evaluate dietary habits (frequency of fruits/vegetables, junk food).

Assess physical activity levels (frequency, duration, type of exercise).

Inquire about smoking and alcohol consumption habits.

Evaluate sleep patterns (duration, quality, disturbances).

Identify the individual’s job title and responsibilities.

Assess exposure to hazardous materials or conditions.

Evaluate stress levels related to job demands.

Inquire about the use of personal protective equipment (PPE).

Assess living conditions (housing quality, neighborhood safety).

Inquire about exposure to environmental toxins (air quality, water safety).

Evaluate access to healthcare services and resources.

Assess social support systems (family, friends, community).

Inquire about current mental health status (anxiety, depression).

Assess coping mechanisms for stress and challenges.

Evaluate support networks available for mental health.

Document any previous mental health treatment or interventions.

Summarize findings from each section.

Identify potential health risks and safety concerns.

Provide recommendations for risk mitigation or improvement.

Schedule follow-up assessment if necessary.

Obtain signature of the individual being assessed.

Obtain signature of the assessor.

Include date of signatures.

Document consent for information sharing if applicable.

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