Beruflich Dokumente
Kultur Dokumente
Screening
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
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
Result
Category
Blood Pressure
______________ mmol/L
Casual
Op)mal
(below
11.0)
High
(11.0
and
above)
Symptoms
of
diabetes
Glucose
______________ mmol/L
Height
N/A
Weight
______________ Pounds
N/A
______________kg/m2
Waist Circumference
______________ Inches
Normal
High
(male:
above
40
inches;
female:
above
35
inches)
AddiAonal Notes