Annual Physical Form - Asset Health

Annual Physical Form

Annual Physical and Biometrics must be completed, in its entirety, between November 2, 2016 and November 1, 2017 to receive credit for the incentives. Keep this form/confirmation for your records.

Employee Section: TO BE COMPLETED BY YOU (PLEASE PRINT)

Name: DOB: Address: City: Signature:

Email Address:

_ Employee DIN:

State:

Zip:

Today's Date:

@

Physician Section: TO BE COMPLETED BY YOUR PHYSICIAN Annual Physical/Examination Date:

Qualifying Dates: 11/2/16? 11/1/17

Physician's Signature:

Physician's Name (please print):

My physician should complete the biometrics below (Do not complete if you attend a LiveWell onsite health screening)

Blood Work Date:

Height:

feet

Total Cholesterol:

_inches _mg/dl HDL:

Weight:

pounds

Glucose Level:

Blood Pressure:

/

mm/Hg Waist Circumference (if available):

mg/dl inches

Employee is to upload this form by November 1, 2017: Log on to livewell. and select the "Wellness Activity Tracking" tab found at the top of the homepage. First click the check mark, followed by the paper clip to attach your form, then click "Submit." Forms will be processed within 5 business days of upload.

If you have questions or need additional assistance, please contact Interactive Health at DelphiLiveWell@.

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