WISEWOMAN Participant Screening Form
Wayne County Healthy Communities' WISEWOMAN program is designed to help promote heart health lifestyle changes in women for a healthy long life. The program provides women with health screenings, free health coaching, and healthy incentives that promote healthy behaviors and decrease the risk of heart attack, stroke, and diabetes. To qualify for the program, you must be a woman between the ages 40 and 64. You must also meet the following income guidelines:
1 Person household - $31,225
2 Person household - $42,275
3 Person household - $53,325
4 Person household - $ 64,375
Complete this form to get started today.
First Name *
Your answer
Last Name *
Your answer
Date of Birth *
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DD
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Phone Number *
Your answer
E-mail
Your answer
Insurance Status *
Required
Insurance Type *
Your answer
Household Size *
Your answer
Household Income *
Your answer
Which health topics/condition is most concerning to you regarding your health? *
What are your primary health and fitness goals? *
How did you hear about this program? *
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