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Health Screening Survey

First Name: ___________________________Initial ___________Last

Address:____________________________________________________ Zip
Phone Number:
E-mail Address: _________________________________________________________Age
1. Have you ever been diagnosed with High Blood Pressure? 1-Yes 0-No
Not Sure
2. Have you ever been diagnosed with diabetes or high blood sugar? 1-Yes
0-No Not Sure
3. Are you a smoker? 1-Yes 0-No 4 B. Would you like information on
quitting? 1-Yes 0-No
4. Are you a Veteran? 1-Yes 0-No
5. Are you disabled? 1-Yes 0-No
6. Have you been to the doctor in the last year? 1-Yes 0-No
7. Have you been to the Emergency Room in the last year? 1-Yes 0-No
8. Have you had a fall in the past year? 1-Yes 0-No When:__________________
9. Which of the following describe your sleep? Satisfactory Unsatisfactory
Insomnia Sleep apnea Less than 7 hours a night Other ______________________

10. Do you have health insurance? 1-Yes 0-No

Who is your coverage with? BlueChoice First Choice Select Health

BlueCross Atena
Palmetto Physicians Connections Absolute Total Care Carolina Medical
Homes USAA

South Carolina Solutions United Health Care TriCare Humana


Other _____________________________

11. Do you have a health care provider (Doctor, Nurse Practitioner, etc)? 1-
Yes 0-No
Name or
Resource Referral List
12. What would you be interested in participating in any of the following
1-Healthy Living 2-Exercise / weight lifting 3-Healthy Eating/Weight Loss
4-Having a Health Advocate (For those with a Chronic Illness) 5-Being a Health
13. Are you interested in purchasing fresh produce in your neighborhood if
EBT is accepted?
1-Yes 2-No Name of your

14. Would you like to hear about upcoming events related to Healthy
Columbia? 1-Yes 0-No

Medical Care Walk with Ease

Richland Care Arthritis Self Help
Eau Claire Cooperative Health Centers Arthritis Exercise Foundation Program
Innovations Health Summer Adult Coed Kickball league
Best Chance Network Healthy Palmetto Walking Program
Cancer Health Initiative Zumba
Line Dancing
Nutrition and Obesity Related
Resources Vision Care
I am Woman SC Eye Care Initiative 803 296-2251
Better Choices Better Health
Project Fit Physical Activity for Kids
Lifestyle University Ultimate Frisbee League (Greenview
University Lifestyle (children) Park)
Fun Fridays (Hampton Park)
Physical Activity Programs Cardio Explosion
Health Screening Survey
Resources Other Interest:
Benefit Bank ____________________________
Food Referral ____________________________
Produce Truck ____________________________
Dental Care
Richland Care
Community Programs Small Smiles (0-20)
Prescription Assistance
Palmetto Health Smoking Cessation
Palmetto Health Office of Community
Healthy Start
Local Parks and Recreation