You must have JavaScript enabled to use this form. Name First Name (Legal) Last Name (Legal) Mailing Address Address City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Birthdate Email Email Confirm email Phone Number Sex - Select -MaleFemale 1. Do you have SPH Health Insurance? - Select -YesNo 2. Have you established care with a Primary Care Provider? - Select -YesNo 3. Do you currently experience joint or muscle pain with activity? - Select -YesNo 4. Does muscle or joint pain affect your participation in activity or exercise? - Select -YesNo 5. Over the last 2 weeks, how often have you had little interest or pleasure in doing things? - Select -Not at allSeveral daysMore than half the daysNearly every day 6. Over the last 2 weeks, how often have you been feeling down, depressed, or hopeless? - Select -Not at allSeveral daysMore than half the daysNearly every day 7. Do you have a clear understanding of what wellness benefits are available to you as an SPH employee? - Select -YesNo On a scale of 1-5, 1 being not at all and 5 being yes, absolutely. Please rate the following: 8. Does lack of time affect your ability to be active? 1 2 3 4 5 9. How much does social influence have on you being active? 1 2 3 4 5 10. Do you feel like you have the energy to exercise? 1 2 3 4 5 11. Do you feel unmotivated to exercise? 1 2 3 4 5 12. Do you fear being injured while exercising? 1 2 3 4 5 13. Do you feel you lack the skills to use the resources? 1 2 3 4 5 14. Do you feel you do not have the resources you need? 1 2 3 4 5 Verify Birthdate Review Consent and Release of Liability Informed Consent and Release of Liability I request the opportunity to participate in a health screening and personal wellness profile conducted by the St. Peter’s Health Wellness Department. The screening involves the drawing of blood for laboratory testing, and other simple tests. I understand that my participation is entirely voluntary, that the health screening is solely for my own knowledge and benefit, and that I may stop the evaluation at any point. If this screening is part of a work place wellness program, my employer may be provided with an aggregate report. This report only includes group data, and does not include any names or personally identifiable information.I understand that there may be variances in test results, and that I should consult with my physician for a comprehensive analysis of my physical condition or any symptoms I may be experiencing. I also understand that the tests which are to be conducted are screening procedures only, not diagnostic in nature. I realize that all results are kept confidential and that it is my responsibility to follow up any abnormal result with my health care provider.I understand that I am encouraged to ask questions about the procedures used in this screening and evaluation. I have read this form and I understand the testing procedures that will be performed.I recognize and accept any risk associated with my participation in this screening and I release St. Peter’s Health from all liability, medical claims or expenses which may arise from my participation, or from any injury sustained during this event. I have read and agree to the Consent and Release of Liability. I request the opportunity to participate in a health screening and personal wellness profile conducted by the St. Peter's Health Wellness Department. The screening involves the drawing of blood for laboratory testing, and other simple tests. I understand that my participation is entirely voluntary, that the health screening is solely for my own knowledge and benefit, and that I may stop the evaluation at any point. If this screening is part of a work place wellness program, my employer may be provided with an aggregate report. This report only includes group data, and does not include any names or personally identifiable information. I understand that there may be variances in test results, and that I should consult with my physician for a comprehensive analysis of my physical condition or any symptoms I may be experiencing. I also understand that the tests which are to be conducted are screening procedures only, not diagnostic in nature. I realize that all results are kept confidential and that it is my responsibility to follow up any abnormal result with my health care provider. I understand that the Employee Wellness RN Care Manager will contact me if my blood pressure is greater than 140/90 or my blood glucose is greater than 110 to discuss resources available through St. Peter’s Health Employee Wellness Program. I understand that I am encouraged to ask questions about the procedures used in this screening and evaluation. I have read this form and I understand the testing procedures that will be performed. I recognize and accept any risk associated with my participation in this screening and I release St. Peter's Health from all liability, medical claims or expenses which may arise from my participation, or from any injury sustained during this event. Submit Leave this field blank