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- Have you used BHA’s screening services before?*
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- Date of Birth*
- Birth Gender*
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Format: (000) 000-0000.
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- Are you a parent or caregiver?*
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- What is your estimated yearly household income?*
- Current Insurance Coverage?*
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- Do you currently have any of the following conditions? (Check all that apply)*
- Have you ever had a heart attack or stroke?*
- Are you currently taking medications for any of the following?*
- Have you ever seen/been referred to a cardiologist/heart doctor since being diagnosed with any of the above conditions?*
- We offer 3 free mental health services would you like to receive a text message?*
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- How often do you engage in physical activity?*
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- Which of the following do you currently have access to? (Check all that apply)*
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- Date Today*
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- 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.*
- 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?*
- 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!*
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