Inova Health Screening PDF Details

The Inova Health Screening form is a comprehensive document designed for individuals participating in health assessments conducted by Inova. It begins with options for the participant to identify themselves as either an employee, a spouse, or a domestic partner, followed by sections for providing detailed patient information including name, address, phone numbers, date of birth, sex, and email. Additionally, employment details and primary physician's name and contact information are requested to ensure a seamless coordination of care. The form also includes a section for patient consent, highlighting the role of Health Diagnostic Laboratory, Inc (HDL) in testing samples for informational purposes and clarifying the non-diagnostic nature of this service. It stresses the importance of individuals consulting their primary care physician with their test results. Furthermore, the form addresses privacy practices, with an acknowledgment that participants have reviewed these practices. Phlebotomist-specific fields are also included to document biometric data such as height, weight, and blood pressure, alongside lab collection details. The form mandates that all entries be typed and signed, emphasizing the procedure for in-person health assessments. Through this meticulous process, the Inova Health Screening form ensures a structured and efficient assessment for participants, fostering a proactive approach to individual health management.

QuestionAnswer
Form NameInova Health Screening
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesinova blood donor screening, inova wellaware health screen form 2019, inova well aware health screening, inova biometric screening

Form Preview Example

 

 

 

 

 

 

 

«Please select one

 

 

 

 

 

 

Employee Spouse or Domestic Partner

 

 

 

 

 

 

 

 

 

 

 

 

PATIENT ID

«

 

ID

 

«

HISTORY

 

EMPLOYEE

 

 

 

 

 

 

 

 

Did you participate in the Inova Health

 

 

 

 

 

Screening in 2014? Yes No

 

PATIENT INFORMATION

 

«Last Name:

 

First:

 

 

 

Middle Iniial:

«Address (Home or Mailing):

 

«City:

 

 

«State:

 

«Zip Code:

 

«Primary Phone:

 

«Date of Birth:

 

 

«Age:

(

)

-

/

/

 

 

 

«Secondary Phone:

 

«Sex:

 

 

 

(

)

-

M

 

F

 

 

 

«Email:

 

 

«Employer Name:

 

 

 

 

 

YOUR PHYSICIAN

INFORMATION

«Physician’s Name:

 

«Pracice Name:

«Pracice Phone Number:

PATIENT CONSENT

I consent to submit my sample to Health Diagnostic Laboratory, Inc (“HDL”) for testing. HDL works with physicians who will order your laboratory test(s) when medically appropriate. These physicians will not diagnose or treat you. The blood testing service from HDL (a) is provided solely for informational purposes and does not constitute treatment or diagnosis of any medical condition or the practice of medicine; and (b) is not being used as a substitute for the care, medical advice, or treatment provided by your primary care physician. You are solely responsible for forwarding your test results to your primary care physician and following up with that individual. HDL and HDL physicians shall not be liable for your failure to consult with your primary care physician or another medical professional following receipt of test results. When you participate in a blood test from HDL, you are doing so with the understanding that you/your employer is privately paying for these tests and there will be absolutely no billing to Medicare, Medicaid, or private insurance. I have read the above terms and conditions and agree to them.

 

 

 

 

 

/

/

 

 

 

 

 

Patient Signature

Date

 

 

 

 

 

 

 

 

 

NOTICE OF PRIVACY PRACTICES

 

 

I acknowledge that I have reviewed HDL Notice of Privacy Practices and understand that it may be revised from time to time. I understand that any changes will be posted on HDL’s website, www.hdlabinc.com, and that I am entitled to receive a copy of the notice upon request.

«

/

/

Patient Signature

Date

 

Office Use Only:

We attempted, but could not obtain written acknowledgment of receipt of our Notice of Privacy Practices, because:

Patient refused to sign

Emergency Situation

Other:__________________________________________________________________________________

PHLEBOTOMIST USE ONLY

 

Has the Paricipant previously had their

 

YES

 

 

NO

 

 

If yes, where?

 

 

 

 

 

 

 

 

labs drawn by HDL?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is the Paricipant

YES

 

NO

 

 

Does the Paricipant have a

YES

 

NO

 

 

 

 

pregnant?

 

 

 

 

 

pacemaker?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Biometrics

 

 

 

 

 

Drawing Lab:

 

 

 

 

 

 

 

 

 

 

 

 

Height:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

feet

 

 

 

inches

 

 

Tel. No.:

)

 

 

 

-

 

 

 

 

 

 

 

Weight:

 

 

 

 

 

 

 

 

 

 

(

 

 

 

 

 

 

ext:

 

 

 

 

 

 

 

 

pounds

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Collecion Date & Time:

 

 

 

 

 

 

 

 

 

 

Blood

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

:

 

 

 

 

 

 

Pressure

 

 

 

 

 

 

 

 

 

 

/

 

/

 

 

 

 

 

am/pm

(mm/Hg):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Systolic

 

 

 

Diastolic

 

 

 

Phlebotomist

 

 

 

 

 

 

 

 

 

 

 

 

Waist

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Circumference

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(inches):

 

 

 

 

 

inches

 

 

Fasing:

 

Yes

 

 

 

 

 

 

No

Body Composiion (%):

 

 

 

 

 

 

 

 

 

 

 

Hrs

 

 

 

 

 

 

 

 

 

%

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Internal Use Only:  All fields with a «are complete.

Location is checked.

Phlebotomist Use Only is complete.

Initial:_______ Date:________

*INSTRUCTIONS:

This form MUST be typed, signed, printed and brought to your health assessment appointment. Handwritten copies will NOT be accepted.

REQUESTING LAB/INSTITUTION

Inova WellAware Health Screening

V1.3

 

HDL Overseeing Physician: Thomas D. Dayspring, MD

 

«Please select your location of employment, or "spouse" if applicable

Inova Fairfax Medical Campus - 0010898

Inova Alexandria Hospital - 0010899

Inova Fair Oaks Hosptial - 0010900

Inova Loudon Hosptial - 0010901

Inova Mount Vernon Hospital - 0010902

Inova Medical Group - 0010903

Inova Continuum of Care - 0010905

Inova Healthplex-Urgent Care Centers - 0010906

Inova System Office - 0010904

Inova Spouse-Domestic Partner - 0010907

CUSTOM PANELS

Custom Employer Panel

Lipid Panel hsCRP Insulin Glucose HbA1c

TSH

ALT Creatinine Cystatin C LDL-P & HDL-P

Joseph P. McConnell, Laboratory Director 737 N. 5th Street, Suite 103

Richmond, VA 23219

CLIA No. 49D1100708 | CAP No. 7224971 | NPI No.

1629209853

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step 1 to completing inova health screening employees

Provide the appropriate data in the field CUSTOM PANELS, Custom Employer Panel, Lipid Panel hsCRP Insulin Glucose, PATIENT CONSENT I consent to, Patient Signature, Date NOTICE OF PRIVACY PRACTICES I, Date, If yes where, and Has the Paricipant previously had.

stage 2 to filling out inova health screening employees

Put together the crucial information in the If yes where, Has the Paricipant previously had, YESS, Is the Paricipant pregnant, YES NO, Does the Paricipant have a, YES NO, Specimen Informaion, Drawing Lab, Tel No, ext, Collecion Date Time, ampm, Phlebotomist, and Height segment.

Entering details in inova health screening employees part 3

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