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HRA Pre-Assessment
Medihelp Wellness Testing
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HRA Pre-Assessment
Medihelp Wellness Testing
Company Wellness Solutions
Company wellness
Company wellness
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Location
Keystone (Brizoway)
Date
Name of Employee
*
Name of Employee
First
First
Last
Last
Contact Number
Employee Number
*
Age
*
Gender
*
Female
Male
Type of medicals
Basic Medicals
Enhanced Medicals
Full Screening
Do you have diabetes ?
*
Yes
No
Do you smoke?
*
Yes
No
Have you been diagnosed with heart disease?
*
Yes
No
Glucose
*
Glucose Results
*
Low
Good
Borderline
High
Cholesterol
*
Cholesterol results
*
Low
Good
Borderline
High
Blood Pressure Systolic (First Number)
*
Blood Pressure Diastolic (Second Number)
*
Result
*
Normal
Slightly Elevated (systolic 121 to 129, diastolic less than or equal to 80)
High Blood Pressure (Stage 1) Systolic 130 to 139, diastolic 81 to 89
High Blood Pressure (Stage 2) Systolic 140 to 180, diastolic 90 to 120
Hypertensive Crisis - Systolic higher than 180, diastolic higher than 120
Weight
Unit of measurement (height in cm, weight in kg)
Metric
Height
cm
Weight
kg
Height
ft
Inches
in
Weight
lbs
BMI
BMI
Underweight
Normal weight
Overweight
Obese
Results
*
Underweight
Healthy
Overweight
Obese
Comment
Body Posture
Back Posture
Correct
High Shoulder
High Hip
Head Tlit
Scoliosis
Side Posture
Correct
Hollow Back
Flat Pelvis
Slumping
Military
If you are human, leave this field blank.
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