Advance CVD Prevention Screening Program

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 NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Biological Gender*

MaleFemale
Race/Ethnicity (check all that apply)*

White/CaucasianBlack/African AmericanHispanicAsian IndianNative American/Alaskan Native
What is your area of service?*

FirefighterPoliceSheriffEMSDispatcher
In what area do you serve?*

York County, SCChester County, SCLancaster County, SCOther
Height*
Height in inches
Weight*
Weight in lbs
Have you been under the care of a cardiologist within the past 12 months?*

YesNo
Have you experienced any of the following? (Check all that apply.)*

Family History of Early Heart DiseaseHigh or Borderline High Blood PressureHigh or Borderline High CholesterolDiabetes or Pre-diabetesOverweight or ObesePremature MenopauseSleep ApneaHeart AttackStrokeHeart Catherization and or/StentDepression, anxiety
How often do you exercise?*

1 - 3 times per week3 - 5 times per weekDailyNever
Do you smoke?*

1 Pack/day2 Packs/day+3 Packs/dayFormer SmokerHave Never SmokedI am exposed to second-hand smoke
How many hours do you sleep each day?*

Less than 5 hours5 - 6 hours7 - 8 hours9 - 10 hoursMore 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?*

YesNoUnsure
Best time of day to schedule a phone call or Zoom:*

Hour Minutes

AM/PM Option
How did you hear about the Saving the Saviors Program? Check all that apply.*

From my employer/supervisorHuman ResourcesThe Heart2Heart FoundationFacebook adTelevisionRadioNewspaperSocial MediaSearch EngineFriend or Family MemberOther
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.*

YesNoUnsure at this timeI need more information
Date Submitted*

MonthDayYear
Date
Please verify that you are human*
Signature

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