Health Promotion Program Point Totals (May - October 2012)Name:______

Please sign and date each activity you complete on the list. Immunizations should be signed by Public Health or medical office staff. After completing every activity, submit the form to the Penny (Wellness Program Coordinator), orMeghan at EBMS.

Program / Signature / Total
Orientation/Sign-Up: I have attended an orientation and would like to sign up for the Fremont County Wellness Program. (10 pts) / Signature & Date:______
Tobacco Free/Cessation: I have not used tobacco products for 6 months OR
I have completed a Tobacco Cessation Program (see WP Coordinator).
(50 pts) / Signature & Date:______
Health Fair Screening Tests: I had blood work completed at a health fair or by an outside provider. (50 pts) / Signature & Date:______
Health Risk Assessment: I completed my Health Risk Assessment at (50 pts) / Signature & Date:______
miBenefit Utilization: I utilized miBenefit at (10pts) / Signature & Date:______
WorldDoc Utilization: I utilized WorldDoc at (10pts) / Signature & Date:______
Medical Exam: I certify that I have had a medical exam in the past 12 mos.
(10 pts) / Signature & Date:______
Dental Exam: I certify that I have had a dental exam in the past 12 mos.
(10 pts) / Signature & Date:______
Immunizations: I certify that my immunizations are current with Public Health. (10 pts) (signed by Public Health or medical office staff) / Signature & Date:______

Penny Fahey Meghan Hatzenbuehler

F.C. Wellness Coordinator EBMS, Inc.

450 N 2nd St., Rm 300, Lander WY 82520 2075 Overland Ave, Billings, MT 59102

(307) 332-1030 (866) 836-5860

(307) 714-2380 (cell) (406) 655-4311 (FAX)

Health Promotion Program Point Totals (May - October 2012)Name:______

Monthly Activities

Please bring this form with you when you have your weight and blood pressure checked every month. Submit to Penny or Meghan when completed.

Blood Pressure and Healthy Weight Maintenance: Penny, the Wellness Program Coordinator, or Public Health, will initial the boxes verifying the

measurements were taken. Five points will be earned for blood pressure checks, whether or not your blood pressure is normal; however points will not

be recorded for high readings until follow-up action has been taken (such as a recheck within a few days, home monitoring, or a recommended

physician visit for very high readings). If you have your measurements completedby your physician or nurse practitioner, please submit the

measurements to Penny or Public Health and they will sign the form.

Activity Calendars: Calendars can be submitted to Meghan or Penny, as in the previous session. After submitting your calendars, record your total points

for each month in the appropriate box to keep track of your points.

Personal Achievement Program: Logs should be turned into Penny and she will initial the boxes monthly.

May / June / July / August / Sept / Oct / Total
BP Readings (5 pts/mo.) Rechecks may be necessary
Physical Activity Calendar (15-20 pts/mo.) See calendar
Healthy Weight Maintenance (10 pts/mo.)
Personal Achievement Program (10 pts/mo.)
Nutrition & Fitness Presentations (5pts for 4 presentations)

Nutrition & Fitness Presentations: Programs will be offered monthly and you can earn up to 20 points total, with each program worth 5 points.

Programs offered by the Wellness Program can be initialed by Penny or a guest instructor. Activities you complete on your own are eligible as long as proof of attendance is provided (see Penny for details). A 5th program can be completed for 5 Bonus Points!

Total Points from One-Time Activities:______+ Total Points from Monthly Activities: ______= Total Points Earned:______

Total Program Reimbursement: ______