Laserfiche WebLink
CITY OF R4SEV�L�E WELLNESS PROGRAM 2005 <br />' ALL INFORMATION GIVEN � VOLUNTARY & WiLL BE KEPT CONFIDENTIAL AS REQUIRED BY HIPPA * <br />Even�lTo ic Verification Points <br />PREVENTION & EARLY DETECTION (In this <br />category, if you ha�e completed as listed & Eia�c included the verification you may take the <br />points each trimester. However, lcee� a copy for future use as iIR will not.) <br />holesterol Screening - Annually <br />lood Pressure Screening - Annually <br />lood Glucose - Annually <br />ody cornpositian! Body Mass Index -B€-Annualty <br />�e�bility Screening - Annually <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 <br />Annual Vision & I�tearing Screening - An�z�ally <br />I'iu vaccination -Annually <br />Dental visiticleaning - every 6 f:iy5. <br />Completed I-�P Health Assessment or other health survey initiated by City -- Annually <br />Participate in MP "Care Span" or other disease management program - Ongoing <br />TOTAL PREVENTION & EARI.Y 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 />tin �:tii.7C�l 7v1: r•' i�S ��.�':k_ng, gardk�i �I�. L':'' =11: Ilt. L'.k� i: ikil:e I <br />Pi�h i�i p�il�c:l u_ a[. �iirure�nix�Ce S�oYI �i` a-t{U �ryf bF-�' S[ i.� h�yek�Y•, va�'n�d I, VI}IL£.VF.4L'I_ <br />basketball, bowling). <br />Participated in an organized Event or Race (Run/I:o[l for the �oses/Bike Ride, AIDS <br />itidelRun, Race for Cure walk, TC Marathon, Triathlon...} <br />Participated in workplaec walk club consistently for the trimester (See 7o[�nda - Engin.} <br />I'�ivii��llll'SnbCf Uf FICB�I�t C'�llb ti1r {:7;iSS 9�{i �[1 �,1ra�t * nrn��p� month <br />�}uu k'r�nci;.it��i ��• park h'.h� Farl�si n�k�q� �p�yt �nt� 1ai�t k�i� �lo�i: s ra�c� � 41t� <br />elevator or escalator? <br />TOTAL HEALTHY LIFESTYI.E - PHI'SICAL ( 10 POSSIBLE ) <br />HEALTHY LIFESTYLE - NUTRITIONAL <br />Participated in a healthy cooking or nutrition class. <br />Do you eat at least 5 servings of fruits and vegetables 5 days or more a week? <br />Do you read nutritional labels prior to purchasing the food you eat? <br />Participated in Healthy Potluck or departmental health snack day. <br />! maiESt.t'tn � hudti f�;k io�.x ti9:at =s stjuslcizreJ lnQlth�:��� �i s E� - 2dj. <br />a�t'�'h�.l]E�4LTli''i LIFES�LE-�1t��i��T�V�r���3�'*�L?.{?i�TiX.t:} � <br />HEALTHY LIFESTYLE - SOCIAL <br />Volunteered time to charity (soup line server, Rosevi[le Arboretum or Nature Center, <br />Clean up day, paint-a-thon) <br />Donated blood <br />Current legal organ donor <br />Consistently ask your doctor or pharmacist for the lowest cost/generic prescription when <br />you get a prescription filled and order any maintenance medications thru mail order? <br />TOTAL HEALTHY LIFESTYI.E - SOCIAL ( 4 POSSIBLE ) <br />Scresners lnitials/pate: <br />Screer�ers lnifrals/Date: <br />SGreeners lnitials/Date: <br />SCIeeRBIS IniCrals/Date: <br />Screeners lnitrals/Dafe: <br />5creeners lnifials/�a #e: <br />5craeners lnitials/Date: <br />Screeners lnrtials/Qate• <br />Screeners lAiFals/f�aie; <br />AttaCh confirmation page: <br />SGreeners lniirals/f�ate: <br />cw w��- tiw�,- <br />Registrafion Form Affached: <br />Regisfration F o n Affached: <br />�'r� Your Hpnar, <br />�oo►w �1�*±ti me+�sr�o �tac�ca <br />On YourHonor <br />Registration Form/5ignature q�taChed: <br />On YourHonor.� <br />On Your Honor.� <br />pn }'u:Y Honor <br />�r6ad�{Elrly^a =�'� <br />Chanty Supervisor5ignaFut�; <br />Screeners lnitialsiDate.• <br />Copy Driver's Liaense/!D: <br />On YourHonor.� <br />� <br />� <br />[■ <br />� <br />� <br />� <br />� <br />� <br />■■ <br />■ ■ <br />��■ <br />-❑ <br />�� <br />Li C.� <br />� <br />�� <br />❑ <br />Q <br />• ■ <br />� <br />� <br />� <br />� <br />� <br />�■ <br />� <br />C:li�acurnents and Seltingslcarolyn.curfilLoca! Sett€ngslTemporary Internet Flla�'+�LK�D2',ti'�cll�r_-xs Program ActivitiesTracking F���pf�f 2 <br />