FUMC Health Fair Pre-Registration Form
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Date of Health Fair: September 15, 2012
First United Methodist Church
6201 Belcrest Road
Hyattsville, MD.
1
. Demographic Information
Demographic Information
First Name:
Last Name:
Zip Code:
Arrival Time:
Gender (Male/Female)
2
. Which Educational Services Do You Need:
Yes
No
Nutritional Information
*
Which Educational Services Do You Need: Nutritional Information Yes
Nutritional Information No
Smoking Cessation
Smoking Cessation Yes
Smoking Cessation No
Violence Prevention
Violence Prevention Yes
Violence Prevention No
Cancer Assessment
Cancer Assessment Yes
Cancer Assessment No
Heart Disease Prevention
Heart Disease Prevention Yes
Heart Disease Prevention No
Holistic Wellness
Holistic Wellness Yes
Holistic Wellness No
3
. Which Medical Services Will You Use?
Yes
No
Blood Pressure Assessment
*
Which Medical Services Will You Use? Blood Pressure Assessment Yes
Blood Pressure Assessment No
Body Mass Index Assessment
Body Mass Index Assessment Yes
Body Mass Index Assessment No
Diabetes Screening
Diabetes Screening Yes
Diabetes Screening No
Cholesterol Screening
Cholesterol Screening Yes
Cholesterol Screening No
HIV Screening
HIV Screening Yes
HIV Screening No
Cancer Screening
Cancer Screening Yes
Cancer Screening No
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