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Wellness Program Event Registration
Focusing on Physical, Spiritual & Nutritional Health
Event Time: January 2021 - March 2021
Event Location: UMZ
Contact Dr. Darrlyn Cornelius-Averhart e-mail:
zrv4@cdc.gov
or e-mail:
UMZChurch@gmail.com
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Name
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Email
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Street Address
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City
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State
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Zip
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Email
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Weekly Exercise
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Daily
1 - 2 times/week
3 - 4 times/week
5 - 6 times/week
Current Weight
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Measurements: Chest
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Measurements: Waist
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Measurements: Hips
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Goal for the program:
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Any Chronic Health Issues: Check any that may apply
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Arthritis/rheumatic Disease
Breathing/Lung Disease (e.g., asthma, emphysema, bronchitis)
asthma, emphysema, bronchitis)
Cancer or Cancer Survivor
Chronic Pain
Depression/Anxiety Disorders
Diabetes
Heart Disease
High Cholesterol
Hypertension (high blood pressure)
Multiple Sclerosis
Osteoporosis (low bone density)
Pre-Diabetes
Stroke
Poor flexibility/Strength
Chronic illness/disability
Unhealthy lifestyle and/or habits
Fear of falling or history of falling in the past
Alcohol Abuse
High Stress
Tobacco Use
Unhealthy Diet and Nutrition
Substance Use/Abuse
Dental Health
Communicable Disease
Prenatal Care
Pneumonia
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