HEALTH RISK ASSESSMENT

Event *

First Name *

Last Name *

Age *

Gender *
Male: Female:

Street Address *

Address Line 2

City *

State*

Zip Code*

Telephone*

e.g : 9876543210 (should not start with 0 or 1)

Do you have a Primary Care Physician?*

Yes
No
Unknown

Ethnicity

How would you like to receive your results?*

Paper Copy

Consent for Text Messages and/or Email*

Hackensack Meridian Health would like to send you Health & Wellness information via text message or email. You’ll receive up to 1 text or email each week. Your information will not be shared or used for any other purpose. You may unsubscribe at any time. For text messages, text STOP to unsubscribe; text HELP for help. Message & data rates may apply. For email click the Unsubscribe link in the email.

If you would like to receive these messages, check the box below.
Text messages (When you receive the first text, reply YES to confirm your subscription.)
Email (When you receive the first email, click the link to confirm your subscription.)

Mobile Number

e.g : 9876543210 (should not start with 0 or 1)

Consent & Release for Screenings*

I hereby give permission for any/all of the screenings below and consent to the drawing of a blood sample by way of a finger stick, when indicated. I have been informed that if I have any questions regarding the nature of the test, its expected benefits, its risks and alternatives tests, I should ask those questions before I consent to the test. I hereby release Hackensack Meridian Health, its directors, officers, physicians, agents, and all others involved in this screening, from any and all liability related to this blood drawing, including but not limited to, performance of the examination and tests, and failure to correctly discover and report to me results, and any failure to make correct recommendations. I understand that, by administering this test, Hackensack Meridian Health is not assuming any responsibility for my care and/or diagnosis and treatment, and I have been advised to consult my personal physician if I have any questions concerning the test or test results*

I Consent

Protected Health Information*

I have received a copy of the Notice of Privacy practices for Protected Health Information (the “Notice”). This notice provides a complete description of the uses and disclosures of my Personal Protected Health Information ("PHI"). I have had an opportunity to review this information before signing this form. I consent to the Hospital and/or any physician(s) participating in my care releasing my PHI (either in writing or verbally) to carry out treatment, payment of health care operations. I understand I may restrict how the PHI is used or disclosed. While the Hospital will make every effort to comply with my request, it is not required to agree with this restriction.*

I Consent

Personal Health History

Do you exercise for 30 minutes or more, three times a week?

Yes
No

Do you currently smoke?

Yes
No

Do you have high blood pressure?

Yes
No

Do you take blood pressure medication?

Yes
No

If yes, which medication?

Do you, or does any blood relative, have diabetes?

Yes
No

Do you take diabetes medication?

Yes
No

If yes, which medication?

Do you, or does any blood relative, have high cholesterol?*

Yes
No

Do you take cholesterol medication?*

Yes
No

If yes, which medication?

Have you, or has any blood relative, had a stroke, heart attack, or bypass surgery?*

Yes
No