Wellness Registration Form
For Therapy Services Employees only
Name/Nombre:
*
First Name/Nombre
Last Name/Apellido
Insurance/Aseguranza
Insurance Name
Member ID
Today's Date/Fecha
*
/
Month
/
Day
Year
Mailing Address/Direccion de Correspondencia:
*
Street Address/Dirección
P.O. BOX
City/Ciudad
State/Estado
Zip Code/(Código postal)
Date of Birth/Fecha de Nacimiento:
*
/
Month
/
Day
Year
Social Security/Seguro Social:
*
Email/Correo Electronico:
*
example@example.com
Phone Number/Numero de Telefono:
*
Gender/Genero:
*
Please Select
Male
Female
Age/Edad:
*
Please check which tests are to be performed/Favor de elijir las pruebas que seran realizadas:
*
Complete Lab Profile (CBC, CMP, Lipid Panel, TSH, Free T4, HGB A1C, Vitamin D, PSA Screening for Men Only)/Análisis Completo de Sangre (CBC, PMC, Panel Lipídico,TSH, T4 Libre, Hemoglobina A1C, Vitamina D)
Height/Weight (Altura/Peso)
Blood Pressure (Presión Arterial)
Body Fat Analysis (Análisis de Grasa Corporal)
Flu Vaccine
Contraindication (see below) the influenza vaccine should not be taken by certain individuals. Please check any that apply.
*
Decline the flu vaccine.
Are you sick today?
Do you have allergies to medications, food, a vaccine component, or latex? Such as: neomycin, eggs, gelatin, MSG? Please list:
Have you ever had a serious reaction after receiving a vaccination?
Do you have long-term health problems with heart disease, lung disease, asthma, kidney disease, metabolic disease (ex: diabetes), anemia or other blood disorder?
Do you have cancer, leukemia, HIV/AIDS or any other immune system problems?
In the past 3 months have you taken medications that affect your immune system such as prednisone, other steroids, or anticancer drugs; drugs for the treatment of rheumatoid arthritis, Crohn’s disease or psoriasis; or have you had radiation treatments?
Have you had a seizure, brain or other nervous system problems? Such as Guillain-Barre Syndrome or other nervous system problems?
During the past year, have you received a transfusion of blood or blood products, or been given immune (gamma) globulin, or an antiviral drug?
For Women: Are you pregnant or is there a chance you could become pregnant during the next month?
Have you received any vaccinations in the past 4 weeks?
I have read the contraindications and DO NOT have any.
Signature/Firma
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