WellSolutions Program Work Order

Account Information

Client LogIn ID: *

Submitted Date:

Account Name: *

Contact Person: *

Phone Number *

Street Address: *

City *

State: *

Zip Code *

Email Address *

Requested By/Account Mgr: *

Account Mgr Email Address: *

Account Mgr Phone #: *

Event 1 Information

Event Type *

Event Room # or Room Name: *

Date Event 1: *

Event 1: Please indicate AM or PM *

	Start:	End:
Time:	Start:	End:

Address for Event 1: *

# of Employees: *

# of Estimated Participants: *

Parking & Entrance Instructions: *

Other Languages:

Event 2 Information

Date Event 2:

Event 2: Please indicate AM or PM

	Start #2:	End #2:
Time:	Start #2:	End #2:

Address for Event 2:

Event Room # or Room Name:

# of Estimated Participants:

# of Employees:

Parking & Entrance Instructions:

Other Languages:

Event 3 Information

Date Event #3:

Event 3: Please indicate AM or PM

	Start #3:	End #3:
Time:	Start #3:	End #3:

Address for Event 3:

Event Room # or Room Name:

# of Employees:

# of Estimated Participants:

Parking & Entrance Instructions:

Other Languages:

Screenings

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
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
TC/HDL/Glu	1	2	3	4	5
TC/HDL/Glu/Tri/LDL	1	2	3	4	5
BMI Only	1	2	3	4	5
BMI & Waist Circumference	1	2	3	4	5
Waist to Hip Ratio	1	2	3	4	5
BMI & Waist to Hip Ratio	1	2	3	4	5
DermaView/Sun Safety	1	2	3	4	5
Hand Grip Strength	1	2	3	4	5

Health Education Programs

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:

Nutrition

	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:

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:

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:

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:

Preventive Health

	I would like to schedule the following:
Sun & Skin Safety	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:

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:

Smoking Cessation

	I would like to schedule the following:
Quit Tips	I would like to schedule the following:
Freedom from Smoking	I would like to schedule the following:

Miscellaneous Services

Choose # of stations/Staff:

	1	2	3	4	5
Admin/Registration Staff	1	2	3	4	5
Flu Shots	1	2	3	4	5
Health Educator	1	2	3	4	5

Immunizations

Hepatitis B

Shingles

Pneumonia

Tdap

PPD