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CITY OF ROS�1/�L,L�E WELLNESS PROGRAM 2005 <br />* ALL INFORMATION GIVEN IS VOLUNTARY & WILL BE KEPT CONFIDENTIALAS REQUIRED BY HiPPA" <br />(In tl�is category, if you have completed � listell & have included tho verification yuu may take !he pnints each <br />trimester.) <br />Cholesterol Screening • Annually Screeners lnitrafs/�ate; OD <br />Blood Pressure Screening -Annually Screeners frritials/pate: ❑ <br />BloodGlucose -Annually 5creenerslnitiafs/Date: OD <br />Body composition/ Body Mass Index -Bi-Annually Screenerslnitials/Date: 0 <br />Flexibility Screening - Annually Screeners lnitials/Date,- ❑ <br />Annual Physical of recommended tests for your age & risk leave. May include things like <br />bone density, pap test, prostate exam, mammogram, colon... -Annually Screeners lnitials/Oate: C_ J <br />Annual Vision &Hearing Screening -.4i�nually 5creenerslnitials/Date: ❑ <br />Flu vaccination -Annually Screeners lnitials/Date: 17 <br />Dental visiticleaning - every 6 mos. ScreenerslnrtialsiQate,- Oi7 <br />Completed HP Health Assessment or other hea[th survey initiated by City --Annually Attach canfirmatron page: d� G <br />Participate in HP °Care Span" or other disease managemenl program - Ongoing 5creenerslnFtials/Date.� C�C�O <br />TOTAL PREVENTION & EARLY DETECTION POINTS ( 20 POSSIBLE) <br />HEALTHY LIFESTYLE - PHYSICAL <br />Moderate activity at least 30 minutes per day no less than 4 times per week outside of any <br />organized activities. (walking, gardening, cleaning, exercising) On vpur�rpnor; Q= <br />Participated in ataarr�lorganizcd sport on aregular basis (i,e. hockey, softball, volleyball, <br />basketball, bowling). Registration Form Attached: �❑ <br />Participated in an organized Event or Race (RunlRoll for the RoseslBike Ride, AIDS <br />RidelRun, Race for Cure walk, TC Marathon, Triathlon...} RegistrationFormAttached: Oi7 <br />Participated in workplace walk club consistently far the trimester (See Jalinda - Engin.} on YaurNonorr C� <br />I'�i} ir.? i•7^i�•�ht�i ti7= : 14,� !I ��'��.iIL ::�• k 1�5� <ilitii r.� v: .:..-1 8 li ii' � �ti, i il7��i'�117. r•ca' a�' cA�enl.r�e,rte.�z`�: "a= h[ky. j C�� <br />I}U r\IL' L'�I.l}14'.L'!IIIti' ��rk i-. lii�'.�irl�i��l �i�.i�i� •�:�i �u:tl -ak�'hc Si7ir� r��l:x:r I'���r. Ih� ��It�x•��i� <br />or escalator? OR'f�u.;�„� ❑ <br />TOTAL HEALTHY LIFESTYLE - PHYSICAL (10 POSSIBLE) <br />HEALTHY LIFESTYLE - NUTRTTIONAL <br />Participated in a healthy cooking or nutrition class. Registration Fonrr/5rgnature Attached: � <br />Do you eat at least 5 servings of fruits and vegetables 5 days or more a week? On Yaur Ho�ror.� C7 ❑ <br />Do you read nutritional labels prior to purchasing the food you eat? Orr YourNonor.• ❑ <br />Participated in Healthy Potluck or departmental health snack day. 4n Your Honor: ❑ <br />I maintain a body fat index that is considered healthyldesirab[e (i.e.. 18 - 26). Attach body fat index sheet: �l� <br />TOTAL HEALTHY LIFESTYLE - NUTRITIONAL ( 7 POSSIBLE ) <br />HEALTHY LIF'ESTYLE - SOCIAL <br />Volunteered time to charity (soup line server, Roseville Arboretum or Nature Center, Clean up <br />day, paint-a-thon) Charity Superoisor Signature: CI <br />Donated blood ScreeRers lnirratsioate: ❑ <br />Current legal organ donor CopyPriver'sLicense/!D: 0 <br />Consislently ask your doctor or pharmacist for the lawest costlgeneric prescription when you <br />get a prescription tilled and order any maintenance medications thru mail order? onY�ur�onor.� ❑ <br />TOTAL HEALTHY LIFESTYLE - SOCIAL( 4 POSSIBLE � <br />llmetro-inei,usl�tosevillelAdminisirationlW R1B�N�FiTSl6enefits & Wellness CommlfteelWel[ness Yrogram ActivitiesTracking �,rf��s of 2 <br />