Health

Screening

Screening Ques)onnaire and Consent Form

Acknowledgement of Risks and Side Eects and Informed Consent Waiver

I acknowledge and I understand:

The poten)al risks and/or side eects have been explained to me.
I voluntarily assume all risks related to my par)cipa)on.
I will have my nger pricked in order to provide a blood sample to a registered health professional for blood glucose and
blood cholesterol measurements.
Most people experience slight discomfort with this procedure.
The incidence of infec)on with this procedure is very low and might be inuenced by variables such as immune deciency.
I may ask any ques)ons or request further explana)on or informa)on about the procedures at any )me before, during or
aDer the screening.
I have had the opportunity to ask ques)ons which were answered to my sa)sfac)on.
I may stop or delay any further tes)ng if I so desire.
Screening may be terminated by the registered health professional upon observa)on of any symptoms of undue distress or
abnormal response.
I waive and release any and all claims, causes of ac)on, liability or damages that I, or anyone claiming on my behalf, may have
against The Health Team and each of their directors, ocers, employees and agents arising from or related in any way to my
par)cipa)on in this screening ini)a)ve, including but not limited to, on account of any injury or damages I may suer as a
result of this nger prick or the results.
The purpose of the screening program is to heighten my awareness and educa)on of the screening topic.
All measurements obtained are for screening purposes only and are not diagnos)c in nature.
These gures do not cons)tute, and should not be subs)tuted for, professional medical advice.
I am urged to consult with my physician for diagnosis and treatment of any health related condi)on.
Any personal contact or results informa)on I provide will form part of a conden)al database. Under no circumstances will
iden)able individual data be made available to any third party. By comple)ng this form, you have agreed to release this
informa)on, and for it to be made available to The Health Team.

I give my consent to have a registered health professional perform and provide results for the following health related
measurements:
Blood pressure
Total blood cholesterol
Blood glucose

Height
Weight

Body mass index

Waist circumference

I, the undersigned, have read, understood and agree to the terms and condiAons set out above. My signature conrms my
consent to the parameters around the collecAon, use and disclosure of my personal health informaAon by The Health
Team.
Name: _____________________________________ Signature: ____________________________________
Witness: ________________________________________ Date: ____________________________________
Contact InformaAon
Address ___________________________________________________________________________________
City _____________________________________ Province ____________ Postal Code __________________
Email ____________________________________________ Phone ___________________________________
The Health Team, 2012

Health Screening
Results Tracking Form

Preliminary QuesAons
Date of Birth: __________________ Age: ____________
Gender: Male Female Smoking Status: Yes No Former Smoker
Blood Pressure MedicaAon? Yes No

Measurement

Are you pregnant? Yes No N/A

Result

Category

Blood Pressure

Systolic ______________ mmHg

Diastolic ______________mmHg

Op)mal (systolic below 120 AND diastolic below 80)

Normal (systolic below 130 AND diastolic below 85)
Normal-high (systolic:130-139 AND/OR diastolic: 85-89)
High (systolic: 140 and above OR diastolic: 90 and above)

Total Blood Cholesterol

______________ mmol/L

Op)mal (below 5.2)

High (5.2 and above )
FasAng (8 hrs. or more)
Op)mal (below 7.0)
High (7.0 and above)

Casual
Op)mal (below 11.0)
High (11.0 and above)
Symptoms of diabetes

Glucose

______________ mmol/L

Height

_________ Feet _________ Inches

N/A

Weight

______________ Pounds

N/A

Body Mass Index

______________kg/m2

Underweight (less than 18.5)

Normal (18.5-24.9)
Overweight (25-29.9)
Obese (30 and above)

Waist Circumference

______________ Inches

Normal
High (male: above 40 inches; female: above 35 inches)

AddiAonal Notes

The Health Team, 2012