Get Screened – Warren and Denyse Mackey Foundation

Your Health is Very Important to Us!

That is the reason that HEART of HOPE, THE WARREN & DENYSE MACKEY FOUNDATION, MVP, CDPHP and ALBANY MED have teamed up to offer you preventative health screening services and information.

Health Screening Form

(Estimated time burden: 15 min) Please enter the requested information below. This information will remain confidential and used only for the stated purpose of providing you with a free preventative health screening.

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About You

Your Name(Required)

First Last

Date of Birth(Required)

Age(Required)

Your current age

Ethnicity(Required)

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

Hispanic or Latino

Gender(Required)

An address where you can receive mail(Required)

Street Address Address Line 2 City State ZIP Code

We understand this may be a sensitive question, but we only seek to know where you can receive physical mail.

How Can We Reach You?

We will review your information and follow up. How can we get in touch?

Preferred Method of Contact(Required)

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Best time of day for an appointment(Required)

If we need to schedule an appointment, what time usually works best for you?

Preferred day for an appointment(Required)

If we need to schedule an appointment, what day usually works best for you?

Health Questions

Please answer these Preliminary Screening Questions so that we can better serve you.

Are you a smoker?(Required)

Do you have a Primary Care physician?(Required)

What is the name of your Primary Care physician?(Required)

Do you currently see a medical specialist?(Required)

Are you under the care of a GYN, GI, or Urologist?

What's the name of your specialist(Required)

Have you recently had a mammogram or CT scan?(Required)

Answer Yes if images (x-rays) were taken of you.

What is the name of the place where your images were taken?(Required)

Who took your CT or Mammogram images?

Are you aware of any HIGH RISK health factors?(Required)

Any conditions that you have or that are known to run in your family?

What are the High Risk health factors that you know about?(Required)

eg. High blood pressure, cancer, heart disease..

Are there specific health services that you believe you need currently?(Required)

What health service do you feel you need right now?(Required)

Insurance?(Required)

Final Questions

How did you hear about us?(Required)

Please specify how your heard about us.(Required)

Is it OK to contact you regarding your gift card (upon screening completion) and for feedback on the preventative health program experience?(Required)