National Tour

Guard Your Heart

Cardi V National Tour
Section 1: Participant Information
Have you used BHA’s screening services before?*

yesno
PLEASE ASK A TEAM MEMBER TO ENTER YOU TESTING CODE*
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Birth Gender*

MaleFemale
Race/Ethnicity*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Section 2: Income & Household Info (Grant Reporting Only)
Are you a parent or caregiver?*

YesNoPrefer not to say
How many people live in your household (including you)?*
What is your estimated yearly household income?*

Less than $15,000$15,000 – $24,999$25,000 – $34,999$35,000 – $49,999$50,000 – $74,999$75,000 – $99,999$100,000 or morePrefer not to say
Current Insurance Coverage?*

PrivateMedicareInsured through employerNo coverageMedicaidMilitary
Enter city of today's event? i.e. Dallas, Washington, Atlanta*
State of Residence *
What is your home zip code*
Section 3: Health Information
Do you currently have any of the following conditions? (Check all that apply)*

CancerHigh blood pressureHeart ProblemsBad CholesterolDiabetes/SugarLiver DiseaseMental Health Disorders (e.g., bipolar, depression, anxiety, etc.)Kidney DiseaseObesityStressNone of the above
Have you ever had a heart attack or stroke?*

YesNoPrefer not to say
Are you currently taking medications for any of the following?*

Blood pressureCholesterolDiabetesHeart diseaseNonePrefer not to say
Have you ever seen/been referred to a cardiologist/heart doctor since being diagnosed with any of the above conditions?*

YesNo
We offer 3 free mental health services would you like to receive a text message?*

YesNo
Section 4: Lifestyle & Access
How often do you engage in physical activity?*

DailyA few times a weekRarelyNever
How would you rate your current stress level?*
Which of the following do you currently have access to? (Check all that apply)*

Healthy, affordable foodReliable transportationHealth insuranceInternet access at homeA primary care doctorNone of the above
Section 5: Media Release
Date Today*

MonthDayYear
Date
I acknowledge that, while participating in this screening, I may be photographed, and or videotaped. Black Heart Association, and partners, may use this material for promotional, educational and advertising purposes.*

I acknowledge
Section 6: BHA Consent & Preferences
Procedure Description: I understand that as part of the screening process, a small sample of blood will be collected either by venipuncture or finger prick.Risks Acknowledgment: I am aware of the associated risks, which include but are not limited to:BleedingVessel injuryBruisingInfectionDisclaimer of Relationship: I acknowledge that participation does not create a patient/doctor relationship with BHA, its affiliates, or any healthcare providers involved.Emergency Authorization: In case of an emergency, I authorize BHA, its affiliates, or healthcare providers to arrange for necessary medical treatment. I agree to hold harmless all parties involved in the administration of such emergency care. I understand that I am responsible for any medical expenses related to the emergency treatments provided.Minor Consent: For participants under the age of 18, a signature from a parent or guardian is required.Communication Consent: By signing this form, I consent to receive periodic newsletters from BHA. I understand that these communications are part of my engagement with BHA and I can opt-out at any time.By typing my name below, I provide my consent for BHA to perform the screening as described above and waive any liability against BHA and their partners for the conduct of the screening.*

I accept the Terms and Conditions
Endless Health's test involves a thoroughly validated, high accuracy, prick testing, Tests are processed in an FDA-certified CLIA lab. Although it is a relatively safe procedure, there are some contraindications and situations where caution is required, check if any of these contraindication are a concern for you, otherwise speak with the organizers of the testing event: Hemophobia Hypotension or Shock Hemophilia Hyperkeratosis Skin Condition Cold Temperature Poor Circulation Burns or Scars Low Platelet Count Allergy to Cleaning Agents Dehydration Edema None of these concerns apply for me and I accept responsibility By participating in this lipid panel screen, you agree to abide by Endless Health Inc's terms and conditions, And agree to and acknowledge Endless Health's privacy policy, and agree to Endless Health's HIPAA notice of privacy practices. The most important parts of the terms and policy are that you acknowledge that you are engaging in a medical test that will generate a medical result, which will be ordered and reviewed by a physician, and returned to you in a secure web portal in accordance with HIPAA. Endless Health does not provide medical advice or medical care. It offers high quality laboratory testing and research-backed lifestyle suggestions for a heart healthy lifestyle. You should discuss your test results with your primary physician or care team.*

TrueFalse
Data is essential for keeping our bus operational and plays a critical role in helping us potentially save lives. We would like your permission to use your data for our white paper, research, or policy/law development. We do not share any identifiable information, and rest assured, we will never sell your personal information. Do you also permit your anonymized data to be used in research to improve health outcomes in communities of color?*

Yes, I consentNo, I do not consent
Would you like to become a member of BHA's "Heart Guard Champion" advocacy program? This program is dedicated to the principles of justice, righteousness, and equity. Our mission is to combat injustice, inequity, and unrighteousness within the healthcare system and beyond. We invite you to join us in our fight by engaging in policy reform, addressing systemic issues, and raising your voice for our patient community. Together, we can create a more just and equitable world. By joining, you’ll also have the opportunity to receive personalized feedback based on your responses, along with ongoing health updates and resources from the Black Heart Association. Join Heart Guard today and be a part of the change!*

Sign me up!Not interested at this time
Section 7: Optional Questions
What is your biggest concern about your health right now?
What would help you feel more supported in your health journey?
All finished! Thank you so much for taking these steps—please go ahead and hit submit!
Should be Empty:

Guard Your Heart

Section 1: Participant Information

Section 2: Income & Household Info (Grant Reporting Only)

Section 3: Health Information

Section 4: Lifestyle & Access

Section 5: Media Release

Section 6: BHA Consent & Preferences

Section 7: Optional Questions

All finished! Thank you so much for taking these steps—please go ahead and hit submit!