Heart4Change Program Enrollment

First Name*

Last Name*

Address*

Street Address City State ZIP Code

County*

Phone*

Email*

Enter Email Confirm Email

Gender*

Ethnicity*

Race*

Date of Birth*

MM

DD

YYYY

Last 4 Digits of Social Security Number*

Please enter a number from 0001 to 9999.

Insurance (Check all that apply)*

Uninsured
Private Insurance
Medicaid
Medicare
Other

Doctor/Health Care Provider:*

Church*

1. Have you had your cholesterol checked within the past 5 years?*

Yes
No

2. Have you been told that you have high cholesterol levels?

Yes
No

3. Are you taking medication for high blood pressure?

Yes
No

4. Do you use any tobacco products - smoke, chew, dip, E-cigs/vape?

Yes
No

5. Do you have diabetes?

Yes
No

6. Have you ever had a heart attack?

Yes
No

7. Have you ever had a stroke?

Yes
No

8. Have you ever been told that you have peripheral artery disease?

Yes
No

9. Do you have heart failure?

Yes
No

10. Are you pregnant?

Yes
No
N/A

11. What size t-shirt do you wear?

Please check all of the following that you are interested in:

HEALTH GOAL: I will work on improving my health by:

Consent*

I agree to the privacy policy.

The Lake Cumberland District Health Department has my permission to perform the screening required to complete the Wellness Check. As part of the Heart4Change program I may receive mailings about LCDHD programs based on my results. I understand I may be tested for (HIV) infections, Hepatitis B, or any other disease carried by blood or body fluids if such a test(s) is needed if a health care worker is exposed to my blood, body fluids or tissue. I also acknowledge that I have been read a copy of the LCDHD Notice of Privacy Practices.

Name

This field is for validation purposes and should be left unchanged.

Enroll for a Heart4Change Program by Completing the Form Below