Advance CVD Prevention Screening Program

Advance CVD Prevention Screening Program

Thank you for your interest in our Frontline Heroes Wellness Fund. Please complete the following self-assessment questionnaire to help our team determine your eligibility to participate in this exclusive program.

All information provided is kept strictly confidential and never shared with any person, group or entity beyond 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
Employer*
What is your area of service?*

FirefighterEmergency Medical ServicesPoliceSheriffDispatch ServicesSchool District PersonnelEducator - TeacherNurseOther
In what area do you serve?*

York County, SCChester County, SCLancaster County, SCMecklenburg County, NCOther
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/StentStress, Anxiety or DepressionOther
Additional comments
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 Frontline Heroes Wellness Fund, 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 Frontline Heroes Wellness Fund? 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 advance labs and screening results with the Frontline Heroes Wellness Fund to assist in a creating your custom lifestyle coaching session.*

YesNoUnsure at this timeI need more information
By submitting this form, I authorize the Frontline Heroes Wellness Fund team to share my self-assessment responses, screening result reports and lifestyle coaching notes as it relates to my participation in this program. Please note this information will NOT be shared with any person not directly associated with this program.*

YesNoUnsure at this timeI need more information
Date Submitted*

MonthDayYear
Date
Please verify that you are human*
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