St. Jam es R - l W ellness Screening Incentive Program 2016-2017 P articip ant Nam e: - The primary care physician needs to complete all information. - No lab reports need to be submitted. - All testing must have been completed between July 1, 2016 - June 30, 2017.

Bio m e tric M easures

Value

T e st D ate (m m /dd/yy)

Systolic Blood Pressure Diastolic Blood Pressure Height (in inches) Weight (in pounds) Abdominal Circumference (in inches) Total Cholesterol LDL Cholesterol HDL Cholesterol Triglyceride Level Glucose (Fasting) Hemoglobin Ale Does your patient have a history of Coronary Artery Disease (Ml, CABG, PTCA)

Yes

Does your patient have a history of Diabetes

Yes

If no, does your patient have pre-diabetes?

Yes

Detach and return bottom section to the Central Office

Physical Confirmation for: (Patient Name)

I verify the above screenings were completed on (Date):

Signature of health care provider:

Office/Clinic Address:

Phone Number:

! / /

No No No