Transcription of Balance for Life Screening Form 2021
1 Balance for Life Screening FormSection I: Patient InformationSection II: To Be Completed By Physician First NamePhone NumberFemaleMaleLast NameLast Four SSNE mailDate of ExamDate ofLab CollectionFastingNoYe sBlood PressureSystolicDiastolicGlucoseTotal CholesterolHDLLDLW eight in PoundsHeight in InchesA1C if indicatedTriglyceridesPreventative Screenings - Physician to determine if the following are medically Smear (for women) within 3 years if 21 or olderColorectal Screening (adults over 50) Fecal Occult Blood Test or ColonoscopyMammogram (for women) within 1-2 years if 40 or olderProstate Cancer Screening (for men)
2 45 or older with family historyNotNeededNotCompletedCompletedPhy sician s Phone NumberDate of BirthPhysician s Name (First and Last)Physician s or LIP Signature DateALL INFORMATION IS REQUIRED. Please review and submit completed form to:Mail: HMC HealthWorks, Attn. Medical Form Department, 140 Intracoastal Pointe Dr. Suite 301, Jupiter, FL 33477 Fax: (Cover sheet not required. Please fax only one person at a time.)Email: (For fax use only - does not accept emails)Complete Blood Count (CBC)Thyroid Stimulating Hormone (TSH)Cholesterol RatioREQUIRED2021
