Wellness Screening Form

Instructions for Submitting External Wellness Screening Results

First Name: Middle Name: Last Name:

Phone Number (555-555-5555 format, please):

E-Mail Address:

8-digit Employee ID Number:

Date of Birth (YYYY-MM-DD format):

Please choose your Campus/Unit:

Screening Results

Screening Date (YYYY-MM-DD format):
Note: Please schedule an appointment via www.healthyforlife.umsystem.edu if your screening date is not between May 1, 2014 and Apr. 30, 2015.

Name of healthcare provider:

Systolic/Diastolic Blood Pressure (xxx/xxx format): /

Height: Feet Inches

Weight: LBS

Total Cholesterol: HDL Cholesterol: Triglycerides:

LDL Cholesterol: Blood Glucose:

  Were you fasting? (please select if YES)

Note: Please verify the form before you submit.
All fields are required.

Confidentiality Notice: Confidential Health Information Enclosed

Protected Health Information (PHI) is personal and sensitive information related to a person's healthcare. It is being faxed to you after appropriate authorization from the patient or under circumstances that do not require patient authorization. You, the recipient, are obligated to maintain it in a safe, secure and confidential manner. Re-disclosure without additional patient consent or as permitted by law is prohibited. Unauthorized redisclosure or failure to maintain confidentiality could subject you to penalties described in federal and state law.

IMPORTANT WARNING: This message is intended for the use of the person or entity to which it is addressed and may contain information that is privileged and confidential, the disclosure of which is governed by applicable law.

If you are not the intended recipient, or the employee or agent responsible to deliver it to the intended recipient, you are hereby notified that any disclosure, copying or distribution of this information is Strictly Prohibited. If you have received this message by error, please notify the sender immediately to arrange for return or destruction of these documents.