Phone 18002521818 - images pcmac 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out Section 1, which requires your healthcare provider's information. Enter the screen date, birth date, and select your gender. Provide your last name, first name, and daytime phone number.
3. Indicate if the screening was not performed due to pregnancy and select your race/ethnicity from the provided options.
4. In Section 2, input your blood pressure readings and other health metrics such as total cholesterol, blood glucose levels, height, weight, and waist measurement. Ensure all fields are filled clearly.
5. Complete the physician’s section by having them fill in their name, type, signature, and contact details. Make sure they also provide any necessary medical history related to high cholesterol or diabetes.
6. Finally, review all entries for accuracy before submitting the form via fax or mail to the ADPH Wellness Program.

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