ActivHealth.com: ActivHealth PHD Network: Personal Health Assessment

Confidentiality -- The results of this survey are confidential. Some of this information may be used by Duke University for research purposes into health trends and issues. However, no information that identifies you personally will be shared with them, or any other entity, without your specific permission. Additionally, if you are a member of a sponsoring organization, your sponsor may receive reports that describe the aggregate health issues of your group. Again, no one, including your sponsor, will receive any personally identifying health information specific to you without your prior consent.

Limitations -- Please keep in mind that the usefulness of this survey is directly related to your ability and willingness to provide accurate information. Since there are many different factors now known to be potential risk factors for certain kinds of diseases and health conditions, a lot of different kinds of information must be obtained. We encourage you to answer each question as accurately as possible. Additionally, the findings resulting from this survey are for personal educational purposes and are not intended to replace a medical evaluation from your physician.

After completing the Personal Health Assessment, you will be presented with a list of possible health risks and a list of courses pertaining to these risks. To view these courses, you must be a PHD Network member. Your survey results will be saved, so you can return to become a member at any time.

Become A PHD Network Member Now

If you are not currently a member of the PHD Network, please fill out the form below. If you are a member of a sponsoring organization, you will need your registration code / sponsor code. If not, upon completion of the Personal Health Assessment, you will be offered a subscription to the PHD Network. Participation in this survey does not obligate you to become a PHD Network Member.

Your Password can be any combination of numbers and letters you select. It must have at least four, and no more than six characters total (no symbols or punctuation marks allowed.) Please write it down in a secure place in case you forget it.

Required items are highlighted in red.

Registration Code / Sponsor Code		(Note: If you do not have a registration code / sponsor code, you will be prompted to pay for membership in the PHD network after filling out the Personal Health Assessment. *Upon registration, you will not* need to remember your registration code / sponsor code.**)
Choose a User Name		(Note: You will need to remember/write down your User Name for future use!)
Choose a Password		(4,5 0r 6 Characters Only)
Re-enter Password		(Note: You will need to remember/write down your Password for future use!)
Password Reminder
First Name
Last Name
Zip Code		Zip Code is for security purposes.
Country
Email Address
Email Confirm		Please re-enter your email address for confirmation purposes.
Date of Birth	/ /	Please enter numbers only with a four-number date. Example: mm/dd/yyyy
Education Level:		(years completed)
Marital Status:
Gender:
Ethnicity:		(Note: Your response to the question of ethnicity is optional; however, ethnic origin is a risk factor for certain health conditions.)
Open Field 1		(Note: Leave Open Field 1 and Open Field 2 blank unless instructed otherwise by sponsor. Example: Open Field 1 = Employee ID #.)
Open Field 2

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