100 Day Heart Challenge

UVH 100 Day Heart Challenge

Participant Information
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Please use the date format MM/DD/YYYY (e.g. 11/28/1988)
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What technology do you currently have access to at home? (please mark all that apply)





Health Information/Risk Factors
High cholesterol

High blood pressure

High blood glucose

Overweight

Smoker

If yes, I commit to starting a smoking cessation program as part of my participation in the 100-Day Heart Challenge

Family history of heart disease

If yes, who has had heart disease



Currently take cholesterol/blood pressure/diabetes medications

Challenge Partner
Based on the health information/risk factors listed above, how do you perceive your partner's risk for heart disease


Acknowledgements
I understand there are a very limited number of participants in the 100-Day Heart Challenge. If I am selected, I commit to being fully involved for the entire 100 days and doing all I can to take advantage of the resources that are provided

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I commit to attend training sessions twice a week

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In order to be successful in this challenge, I understand the need for daily exercise

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I commit to attend a weekly nutrition class

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I agree to be interviewed, photographed and filmed during my participation in the Heart Challenge and I understand that information could be used by the hospital, local media and in various social media venues

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I certify that I am not an employee of Intermountain Healthcare. I also certify that my selected partner is not an Intermountain employee

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Readiness Survey
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