RENEW Program Applications
Please visit
www.smhRENEW.com
for program information.
General Information
Today's Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
I am...
*
a current SMHCS Employee
a family member of a current SMHCS Employee (spouse, sibling, parent, child)
a current SMHCS Volunteer
a community member
What is your Employee ID#?
Which department do you work in?
Name of your family member (spouse, sibling, parent, or child)
Where did you hear of the RENEW Program?
*
Word of Mouth
Doctor Referral
SMH Email/Bankshot
SMH Facebook
HealthFit Gym
HealthFit Rehab
HealthFit Facebook
Sarasota Observer Facebook
Sarasota Observer Email
Hospital Billboard
SMH Today
SMH Wellness Fair
Other
If you marked word of mouth, doctor, or other please elaborate:
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Email
*
example@example.com
Home Address
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Race (self-identified)
*
Please Select
American Indian / Alaskan
Asian
Native Hawaiian / Other Pacific Islander
Black / African American
White / Caucasian
Hispanic / Latino
More than one race
Unknown / Opt out
Gender (self-identified)
*
Female
Male
Other/Opt out
Do you have the ability to exercise (not contraindicated by a physician)?
*
Yes
No
Do you own a smartphone with Android or iOS capabilities, and have a moderate level of technology literacy (comfort with apps)?
*
Yes
No
Do you currently have active cancer?
*
Yes
No
Do you currently have, or are recovering from, an eating disorder?
*
Yes
No
Back
Next
Health Status
Please describe your smoking status
*
Please Select
Never
Past
Current
If past smoker, when did you quit?
If current smoker, for how long have you smoked?
Please check off all current diagnoses that apply to you:
*
Family history of heart disease
Prediabetes (A1c 5.7%-6.4%)
Type 1 Diabetes
Type 2 Diabetes (A1c 6.5% or higher)
Overweight or Obese (BMI over 25)
Hypertension (high blood pressure)
High cholesterol
High triglycerides
Sleep apnea
None of the above
Do you have or have you ever been diagnosed with...
*
Coronary Artery Disease (CAD)
Peripheral Vascular Disease (PVD)
Stroke (CVA)
Transient Ischemic Attack (TIA)
Myocardial Infarction (MI, heart attack)
None of the above
If you have had a stroke, TIA, or MI, when was it?
How ready are you to make lifestyle changes to improve your health?
*
1: I am not ready at all
2: I might be ready
3: I am preparing to make changes
4: I am starting to make changes
5: I have already made significant changes
Submit
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