Well-Being Screening October 2024

Well-Being Screening - October 2024
- Fast for 12 hours before your health screening while staying hydrated with plain water.
- Your health screening will take about 30-45 minutes.
- Location: Stoughton Health - Community Health and Wellness Center
- Address: 3162 Cty Rd B, Stoughton, WI.
- Questions: email ASaul@StoughtonHealth.com or call 608-877-3485.
- Financial assistance is available, please contact us for more information.
  Thank you!
Your Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Phone Number*
Employer/Organization*
If you are here as part of a business partnership, please enter your employer. If not employed or retired, please say N/A
Activity Level*
On a Scale of 1 to 5. 1 being sedentary, 5 being very active.
Select Date and Time Slot (10/7/24 or 10/12/24)*
List of health screening categories:
- Height and weight (BMI for population data)
- Blood Pressure
- Body Composition (Body Fat %, Muscle Mass, Visceral Fat Level) OR Waist Circumference
- Bone Density
- Vision
- Blood Glucose
- Cholesterol (Total, LDL, HDL)
- Triglycerides
- Functional Movement Screen
Also included in the Well-Being Program:

A one on one health coaching session for goal setting, answering questions, and education on the screening numbers. Please sign up for coaching by following the link in your confirmation email.

Health Risk Assessment (HRA) survey for finding out where you need to improve for your overall well-being. You will recieve the link and login information after your health screening date.
Additional Comments and Questions
Online Payment Option (Cash or check is okay in person on screening day).
prevnext( X )
Stoughton Health Well-Being ProgramThis cost includes your Health Risk Assessment, use of the health shelf database, screening day, and one follow-up education and coaching meeting.
$35.00



Additional 6 months of coachingCoaching takes place every 4-6 weeks. This can be added after the screening or your first coaching session.
$60.00



Additional 9 months of coachingCoaching takes place every 4-6 weeks. This can be added after the screening or your first coaching session.
$75.00



Total

$0.00

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

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Well-Being Screening - October 2024