Attendee Registration | 10th Annual Minority Men’s Health Fair

* First Name:

Middle Name:

* Last Name:

* Address:

Address 2:

* City:

* State:

* Zip:

Email:

Phone Number:

- -

* Date of Birth:

/ /

* Last four digits of your Social Security number:

* Ethnicity:

* To encourage participation, please tell us how you first heard of the fair:

What screenings are you interested in? Check all that apply.

Blood pressure
Body mass index
Bone density
Cholesterol
Diabetes (blood sugar)
Dental screenings

Glaucoma (eye screening)
Hepatitis C
HIV
Lung health
Kidney function

Oral cancer
Prostate cancer
Sickle cell
Skin cancer
Stress or depression

Have you attended this health fair in the past?
Yes No

Do you have any feedback regarding our past health fairs?

Do you currently see a Cleveland Clinic doctor for your healthcare needs?
Yes No

Can we contact you regarding a research project?
Yes No

Yes, I would like to receive additional information from Cleveland Clinic.