• 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.
  • Format: (000) 000-0000.
  • Date of Birth*
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  • Biological Gender*
  • Race/Ethnicity (check all that apply)*
  • What is your area of service?*
  • In what area do you serve?*
  • Have you been under the care of a cardiologist within the past 12 months?*
  • Have you experienced any of the following? (Check all that apply.)*
  • How often do you exercise?*
  • Do you smoke?*
  • How many hours do you sleep each day?*
  • If you are chosen for the Frontline Heroes Wellness Fund, are you available for the initial discovery call and to schedule your advance screenings?*
  • How did you hear about the Frontline Heroes Wellness Fund? Check all that apply.*
  • 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.*
  • 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.*
  • Date Submitted*
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