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Health Screening
"
*
" indicates required fields
Patient ID:
office staff only
Survey ID:
office staff only
Date
MM slash DD slash YYYY
Place
Name
First
Middle
Last
Date of Birth
Month
Day
Year
Address
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Home Phone
Cell Phone
Email
Race / Ethnicity
African American / Black
Hispanic or Latino
White
Asian
Middle Eastern
Other
Check all that apply
Gender
Male
Female
Age in years
Repeat Participants?
Yes
No
Name of your Doctor
Health Insurance
Yes
No
If Yes : select one
Medicaid
Medicare
Private Plan
Other
Health History
1. Asthma
Self
Family
2. Cancer
Self
Family
3. Pre Diabetes
Self
Family
4. Diabetes
Self
Family
5. High Blood Pressure
Self
Family
6. Cholesterol
Self
Family
7. Heart Disease
Self
Family
8. Stroke
Self
Family
9. Depression
Self
Family
Are you taking any Medicines?
Yes
No
If Yes, Please explain Below
Lifestyle History
In a typical week, how often do you EAT
Fruits?
Rarely (0 – 2 times /wk)
Sometimes (3 – 5 times /wk)
Frequently (6-7 times/wk)
Vegetables?
Rarely (0 – 2 times /wk)
Sometimes (3 – 5 times /wk)
Frequently (6-7 times/wk)
High salt foods?
Rarely (0 – 2 times /wk)
Sometimes (3 – 5 times /wk)
Frequently (6-7 times/wk)
In a typical week, how many days do you take part in at least 30 minutes of physical activity?
0
2
3
4
5
6
7
(examples / circle: walking, biking, jogging, swimming, gardening, other )
Do you smoke?
Yes
No
(Please check YES even if you smoked before)
Consent
*
CONSENT & WAIVER
I hereby consent and assume full and complete responsibility for my voluntary participation in the free health screening provided by CCN. I hereby release and hold harmless CCN, its agents, employees and volunteers from any and all claims resulting from or arising out of my participation in this event. I accept responsibility for any and all loss or claim I may have resulting from or arising out of my participation in this event, including personal injury or damage caused by falls, contact with participants, conditions or negligence of CCN, its agents, employees or volunteers. I am responsible for follow-up of any abnormal test results found at this screening
Staff Use Only
Clinical Data
Weight
lbs
Height
ft
BMI
Blood Sugar
F R
Blood Pressures
1. BP
2. BP
3. BP
Cholesterol
HDL
LDL
Trig
Eye Exam
Normal
Abnormal
Follow-up with an eye specialist
Dental Exam
Normal
Abnormal
Follow-up with an eye specialist
Recommendations
Brief review of results / advice provided
Provided nutrition counseling
Recommended smoking cessation program
Recommended CCN Enrollment
Recommended ACA Enrollment
Recommended f/u with their own PCP
Recommended f/u with a CCN Provider
Recommended f/u with local FQHC – info given
Provided insurance counseling
Recommended go to ER for immediate care
Notes
Survey review details
Date
MM slash DD slash YYYY
Survey reviewed by
Action Taken
Response
Select Payment Method
Pay Online
Pay Offline
Offline Payment Information
Select Enroll Type
New Enrollment for 6 months
Renewal Enrollment for 12 months