Hillsboro Community Wellness Screening Form

Vernon County Health Department

318 Fairlane Drive PO BOX 209 Viroqua, WI 54665 Phone: (608) 637-5251 Email:health@vernoncounty.org
Hillsboro-Community Wellness Screening

Complete the form below to help us better prepare for your visit
$10 Donation
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender*
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What county do you currently live in?
Email*
example@example.com
Occupation:
Physician's Name or Current Clinic of Preference:*
If you do not have a primary physician or clinic, are you interested in finding one?

YesNoI'm not sure

Check the conditions that apply to yourself and/or immediate family member(s):

Would you be interested in more information with any of the following? (check all that apply)

	Yes	No	Do Not Apply
Mental Health/Depression/Anxiety Care
Quitting Smoking
Weight loss/Diet/Nutrition
Fall Prevention

How would you prefer to get more information on any of the above?*

Written or handoutVerbally or just talking about itEmailI would not like any additional information
Patient Signature: I authorize and give written consent to the staff of the Vernon County Health Department to conduct a health screening including blood pressure, pulse, glucose, and lipid panel screening. I understand that the values may require staff to fax & refer me to a health care provider for additional follow up screening and/or care. I understand that it is my responsibility to follow up on values outside of normal limits and seek further medical directives from a provider. *

Clear
Date Signed*

MonthDayYear
Date
Location of Screening (pick one)*

Vernon County Health DepartmentHome VisitCommunity Event
Preferred Appointment Date
Please verify that you are human*
CLINIC USE ONLY
Date
Time
Blood Pressure:   Type a result
Pulse:    Type a result
Glucose:   Type a result
Hours Fasting:   Type a result
Lipid Panel:   LDL:      HDL:     Triglyceride:    Total Cholesterol

Education Provided? Referrals Made?:   To whom
Findings Faxed to Healthcare Provider?:
Providers Fax #:   Area Code   Fax Number


Preformed by:   First Name   Last Name
Payment:
Information given about local healthcare facilities:
Should be Empty:

Vernon County Health Department