Community Participant Sign-Up 2022-2023
Sign-up to get one-on-one, one hour advising from medical students (future doctors) at UAB School of Medicine from Dynamic Health, a new service-learning organization. This does not replace the instruction of your medical providers, but serves as additional information, because we are not doctors.

If you have questions or need help filling this form out please email dynamichealth.uabsom@gmail.com
Sign in to Google to save your progress. Learn more
What organization are you from? *
Name *
Choice of Contact? *
Required
Email *
Number *
What services would you like to receive ? (You can do more than one): *
Required
How often do you want to have health maintenance appointments? *
How often do you want to have other health appointments(including nutrition, exercise, disease education)? *
How many appointments are you willing to have per month?(If you choose multiple things it is difficult to have less than 3 appointments) *
If you picked Disease Education, pick the topics you would be interested in learning more about (you can pick multiple):* *
Required
In general, what days of the week are you most available for any of the activities listed above?*(Can choose more than one): *
Required
What time of day are you most available for any of the activities listed above?*: *
Required
What are your goals and what will you like to take out of this experience? *
What time frame would you be interested in participating in this program *
How would you rate your current understanding of your health? *
No Understanding
Completely Understand
How would you rate your level of happiness of your current health status? *
Completely Unhappy
Completely Happy
How would you rate your belief of the possibility to improve/ change your current health status? *
Can't Do Anything to Improve
Completely Able to Improve
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms