Advance CVD Prevention Screening Program
Thank you for your interest in our program! Please complete the following self-assessment question to help our team determine your eligibility to participate in this free pilot program for first responders and emergency services personnel. All information is kept strictly confidential and never shared with any person, group or entity beyond members of our program team. Please call 803-805-1421 if you have any questions or need assistance.
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Biological Gender
*
Male
Female
Race/Ethnicity (check all that apply)
*
White/Caucasian
Black/African American
Hispanic
Asian Indian
Native American/Alaskan Native
What is your area of service?
*
Firefighter
Police
Sheriff
EMS
Dispatcher
In what area do you serve?
*
York County, SC
Chester County, SC
Lancaster County, SC
Other
Height
*
Height in inches
Weight
*
Weight in lbs
Have you been under the care of a cardiologist within the past 12 months?
*
Yes
No
Have you experienced any of the following? (Check all that apply.)
*
Family History of Early Heart Disease
High or Borderline High Blood Pressure
High or Borderline High Cholesterol
Diabetes or Pre-diabetes
Overweight or Obese
Premature Menopause
Sleep Apnea
Heart Attack
Stroke
Heart Catherization and or/Stent
Depression, anxiety
How often do you exercise?
*
1 - 3 times per week
3 - 5 times per week
Daily
Never
Do you smoke?
*
1 Pack/day
2 Packs/day
+3 Packs/day
Former Smoker
Have Never Smoked
I am exposed to second-hand smoke
How many hours do you sleep each day?
*
Less than 5 hours
5 - 6 hours
7 - 8 hours
9 - 10 hours
More than 10 hours
If you are chosen for the Saving the Saviors Program, are you available for the initial discovery call and to schedule your advance screenings?
*
Yes
No
Unsure
Best time of day to schedule a phone call or Zoom:
*
Hour Minutes
AM
PM
AM/PM Option
How did you hear about the Saving the Saviors Program? Check all that apply.
*
From my employer/supervisor
Human Resources
The Heart2Heart Foundation
Facebook ad
Television
Radio
Newspaper
Social Media
Search Engine
Friend or Family Member
Other
Upon acceptance into the program, you agree to voluntarily share all screening results with the Saving the Saviors team to assist in a creating your custom lifestyle coaching session.
*
Yes
No
Unsure at this time
I need more information
Date Submitted
*
-
Month
-
Day
Year
Date
Please verify that you are human
*
Signature
Submit Application
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