Community Health Programs
Know Your Health Survey and Interest Form
Interest Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Do you know your BMI? (body mass index)
Yes
No
Do you know your blood pressure numbers?
Yes
No
Please indicate which program(s) you are interested in now, for the future, for a family member:
*
Interested Now
Interested for Future
Family Member Interested
Not interested
YMCA's Diabetes Prevention Program (Prediabetes)
Blood Pressure Self-Monitoring Program (High Blood Pressure)
LIVESTRONG at the YMCA (Cancer)
Walk with Ease (Arthritis)
Healthy Weight and Your Child (Childhood Obesity) (coming September 2024)
Availability to participate in program that can be anywhere from 30 min- 1 hr long weekly:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
8 AM
9 AM
10 AM
11 AM
12 PM
1 PM
2 PM
3 PM
4 PM
5 PM
6 PM
7 PM
8 PM
Would you like to receive information about our upcoming Senior Expo?
*
Yes
No
In the past year, have you or any family members in your household been unable to get any of the following when it was needed? Check all that apply
Food
Clothing
Housing
Utilities
Medication or Any Health Care (Medical, Dental, Mental Health, Vision)
Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living? Check all that apply
Yes, it has kept me from medical appointments or
Yes it has kept me from non-medical meetings, appointments, work, or from getting things needed from daily living
No
I choose not to answer this question
Back
Submit
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YMCA Staff ONLY
Contact Log
Patient is: contacted, waitlisted, enrolled, declined, withdrew, completed program
Contacted
Waitlisted
Enrolled
Declined
Withdrew
Completed Program
Submit
Should be Empty: