Cardiovascular Screening
Name
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Race
Please Select
Caucasian
African America
Asian
Native American
Other
Ethnicity
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Hispanic
Non-Hispanic
Unknown
Select all options that apply to you
*
Hearing Difficulty
Vision Difficulty
Cognitive Difficulty
Self-Care Difficulty
Independent Living Difficulty
None of the above
Select all health conditions that apply to you
*
Alzheimer's Disease
Anxiety
Asthma
Cancer
COPD
Depression
Diabetes
Fall Risk
GERD
Heart Failure
HIV
High Cholesterol
High Blood Pressure
Kidney Disease
Liver Disease
Migraine
Multiple Sclerosis
Obesity
Organ Transplant
Osteoporosis
Stroke
None of the above
Other
Home Pharmacy
*
Please Select
Tyson Drugs - Holly Springs
G&M Pharmacy - Oxford
Potts Camp Pharmacy - Potts Camp
Other
Primary Care Physician
Cardiologist (if you have one)
Stroke Risk Assessment
Please answer the following questions. Our staff will then evaluate your risk and provide you with helpful resources to decrease any risk factors you have.
*
Rows
Yes
Unknown
No
Is your blood pressure greater than 120/80 mm/Hg?
Have you been diagnosed with atrial fibrillation
Is your blood sugar greater than 100 mg/dL?
Is your body mass index greater than 25 kg/m2?
Is your diet high in saturated fat, trans fat, sweetened beverages, salt, excess calories? (Excess calories means eating more than your body can burn off in a day.)
Is your total blood cholesterol greater than 160 mg/dL?
Have you been diagnosed with diabetes mellitus?
Do you get less than 150 minutes of moderate to vigorous-intensity activity per week?
Do you have a personal or family history of stroke, TIA or heart attack?
Do you use tobacco or vape?
If you have not been diagnosed with atrial fibrillation (AFib) or if your status is unknown and you are at an increased risk for stroke, we would like to conduct a quick, free and easy AFib screening. Are you interested?
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Yes
No
Social Determinants of Health Screening
Please answer the questions below. One of our staff members will review your answers and provide you resources if you are interested. As a reminder, all information in confidential.
What is your housing situation today?
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I have stable housing
I have semi-stable housing (I stay with family or friends, and move around a lot)
I am homeless (I sleep in shelters or on the street most nights)
Think about the place you live. Do you have problems with any of the following? (Check all that apply)
*
Mold
Bug infestation
Lead paint or pipes
Inadequate air or heat
Oven or stove not working
No or not working smoke detectors
Water leaks
None of the above
What is your current work situation
*
Unemployed and seeking work
Part-time or temporary work
Full-time work
Otherwise unemployed but not seeking work (e.g. student, retired, disabled, unpaid caregiver)
If you have children, do problems getting child care make it difficult for you to work or study?
*
Yes
No
Not applicable
In the past year, have you or any family members you live with been unable to get or afford any of the following when it was needed?
*
Rows
Yes
No
Food
Clothing
Utilities (includes electric, gas, water, etc.)
Child Care
Medicine
Other Healthcare (includes medical, dental, mental health, vision, etc.)
If you are on Medicare or turning 65, do you need help understanding your coverage options to ensure you are on the best possible plan?
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Yes
No
Not applicable
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? (Check all that apply)
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Yes, it has kept me from medical appointments or from getting my medications
Yes, it has kept me from non-medical meetings, appointments, work, or from getting things that I need
No
Would you be interested in resources to assist with any needs listed?
*
Yes
No
By signing below I understand that I will be provided with information and resources from a pharmacist, pharmacy technician, or community healthcare worker at Tyson Drugs/G&M Pharmacy. I authorize Tyson Drugs/G&M Pharmacy to provide any relevant medical information to my primary care physician.
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