WellSolutions Program Work Order

Account Information

Client LogIn ID: *

Submitted Date:

Account Name: *

Contact Person: *

Phone Number *

Street Address: *

City *

State: *

Zip Code *

Contact Email Address:

Requested By/Account Mgr: *

Account Mgr Email Address:

Account Mgr Phone #:

Event Information

Event Type *

Online Reg? *

Yes

No

Vouchers Needed? *

Yes

No

# of Points

Event Room # or Room Name: *

Date Event: *

Event Time: Please indicate AM or PM *

	Start:	End:
Time:	Start:	End:

Address for Event: *

# of Employees:

# of Estimated Participants: *

Other Languages:

Parking & Entrance Instructions:

Screening Services

Choose # of stations/Staff

	1	2	3	4	5
Standard Wellness Clinic (FS, BP, REG, HE)	1	2	3	4	5
A1c	1	2	3	4	5
Blood Pressure	1	2	3	4	5
BMI Only (includes height & weight measurement)	1	2	3	4	5
BMI & Waist Circumference	1	2	3	4	5
BMI & Waist to Hip Ratio	1	2	3	4	5
Body Comp Analysis	1	2	3	4	5
Bone Density	1	2	3	4	5
Carbon Monoxide (CO)	1	2	3	4	5
Chair Massage	1	2	3	4	5
Circuit Screenings	1	2	3	4	5
Cotinine Screening	1	2	3	4	5
DermaView/Sun Safety	1	2	3	4	5
Hand Grip Strength	1	2	3	4	5
Health Educator (results consult)	1	2	3	4	5
Registration	1	2	3	4	5
TC/HDL/Glu	1	2	3	4	5
TC/HDL/Glu/Tri/LDL	1	2	3	4	5
Waist to Hip Ratio	1	2	3	4	5

Other Screening: add here

Health Education Programs

Ask the Pharmacist Series

	I would like to schedule the following:
Understanding OTCs, Supplements & Questions to Ask About Your Medications	I would like to schedule the following:
Myths & Facts about Generic Medications & Exploring Ways to Save on Pharmacy Expenses	I would like to schedule the following:
Nuts & Bolts of Why Medications Are Important and How to Get Help with Medications	I would like to schedule the following:
Ask the Pharmacist: Allergies	I would like to schedule the following:

Health Across the Lifespan

	I would like to schedule the following:
Energy for Life	I would like to schedule the following:
Health Aging	I would like to schedule the following:
Health Families	I would like to schedule the following:
Men's & Women's Health	I would like to schedule the following:
? Tired of Being Tired?	I would like to schedule the following:

Nutrition

	I would like to schedule the following:
Smoothie Demo	I would like to schedule the following:
Healthy Cooking Demos	I would like to schedule the following:
Contemporary Myths & Facts About Nutrition	I would like to schedule the following:
DASHing to Good Health	I would like to schedule the following:
Healthy Eating on a Budget	I would like to schedule the following:
Eating the Rainbow and Feeling "Fiberful"	I would like to schedule the following:
Health Eating on the Go	I would like to schedule the following:
Ask the Dietitian Stop-By	I would like to schedule the following:

Physical Activity

	I would like to schedule the following:
Physical Activity - Exercising the Basics	I would like to schedule the following:
Nutrition for Exercisers	I would like to schedule the following:
Steppin' Out - 6 week Walking Challenge	I would like to schedule the following:

Preventive Health

	I would like to schedule the following:
Sun & Skin Safety	I would like to schedule the following:
Eye Health	I would like to schedule the following:
Bone & Joint Health	I would like to schedule the following:
Heart Health	I would like to schedule the following:
Immune Health	I would like to schedule the following:
Diabetes Awareness	I would like to schedule the following:
Back Injury Prevention	I would like to schedule the following:
HealthCare Basics	I would like to schedule the following:

Stress Management

	I would like to schedule the following:
The Art of Relaxation	I would like to schedule the following:
Coping with Stress	I would like to schedule the following:
Emotional Health - Avoiding the Anger Trap	I would like to schedule the following:
Stop the Juggling	I would like to schedule the following:

Smoking Cessation

	I would like to schedule the following:
Quit Tips	I would like to schedule the following:

Weight Management

	I would like to schedule the following:
Metabolism 101: Weight Management Basics	I would like to schedule the following:
Mindful Eating and Weight Loss	I would like to schedule the following:

Immunizations

Flu Shots

Shingles (Shingrix-2 dose series)

Pneumonia

Hepatitis B

Tdap

PPD