Register For Free Health Clinic

April 22, 2023 11:00 - 1:00pm | Join the Northside SDA Church & 15 community organizations for a special health fair, where you’ll find music, games, food, and prizes plus multiple resources to help you stay active and healthy.

Date

Personal Information

Name

Date of Birth:

Address

Cell Phone

Physical Health

When was the last time you saw a health care professional?

Please select all that apply.

3 months 6 months 1 year Over a year

Do you have medical insurance

Please select all that apply.

Yes No

If yes, list name of medical Insurance

Possible Screenings (please choose the screenings you desire)

Please select all that apply.

Blood Pressure Blood Sugar (Glucose) Cholesterol

Medical History

Have you ever been diagnosed any of the following conditions?

Please select all that apply.

Angina Atrial Fibrillation Congestive Heart Failure Coronary Artery Disease Heart Attack Heart Murmur High Blood Pressure High Colesterol Diabetes Stroke Poor Circulation in Legs Blood Clots in Legs Sleep Apnea Lung Disease Cancer Liver Disease Kidney Disease

Other

Medical Information

Height

Weight

Blood Type

Spiritual Health

Check if you are interested in any of the following. Please select all that apply

Please select all that apply.

I need prayer I need spiritual support I need biblical education services

Other

Mental Health

I would like to speak to a mental health counselor to learn how to manage my stress

Please select all that apply.

Yes! I would like to speak to a mental health counselor No

Nutrition

Check here if you'd like information about how to implement a healthy diet

Please select all that apply.

Yes

Description

April 22, 2023 11:00 - 1:00pm

Join the Northside SDA Church & 15 community organizations for a special health fair, where you’ll find music, games, food, and prizes plus multiple resources to help you stay active and healthy.

Register For Free Health Clinic

Description

Please Fix the Following