South Okanagan Centennial Health Fair Registration

Health Fair Registration - Saturday February 21, 2009
As space is limited it is important that everyone who registers attends. Only complete this form if you are serious about attending. Once there are 300 participants, you can be placed a waiting list.
You are eligible for screening if you are over 19

First Name:	Last Name:
Phone:	Email:
Address:
City:	B.C.	Postal Code:
Preferred Appointment Time:

Please Answer the following questions:

Heart Health Factors I Can't Change

1. Age

2. Gender

3. Heredity - I have a family history of Heart Disease in a first degree relative BEFORE age 55 (males) or age 65 (females) YesNo

4. Personal History - I have diabetes (not during pregnancy) and/or have had Heart Disease (angina, heart attack, coronary bypass and/or stroke) YesNo